Section R4-11-301. Application

A.      An applicant for licensure or certification shall provide the fol- lowing information and documentation on a form provided by the Board:

1.        A sworn statement of the applicant’s qualifications for the license or certificate;

2.        A photograph of the applicant that is no more than six months old;

3.        An official, sealed transcript sent directly from the appli- cant’s dental, dental hygiene, or denturist school to the Board;

4.        Except for a dental consultant license applicant, proof of successfully completing a clinical examination by sub- mitting:

a.         If applying for licensure by examination, a copy of the certificate or score card from the Western Regional Examining Board, indicating that the applicant passed the Western Regional Examining Board examination within the five years immedi- ately before the date the application is filed with the Board;

or

b.        If applying for licensure by credential, certified doc- umentation sent directly from the applicable testing agency or state to the Board containing the name of the applicant, date of examination or examinations, total score for each examination, name of any sepa- rately-scored component of the examination, and scores for each component;

5.        Except for a dental consultant license applicant as pro- vided in A.R.S. § 32-1234(A)(7), an official score card sent directly from the National Board examination to the Board;

6.        A copy showing the expiration date of the applicant’s cur- rent cardiopulmonary resuscitation certificate from the American Red Cross, the American Heart Association, or another certifying agency that follows the same proce- dures, standards, and techniques for CPR training and certification as the American Red Cross or American Heart Association;

jurisdiction to the Board;

8.        If the applicant has been licensed in another jurisdiction for more than six months, a copy of the self-inquiry from the National Practitioner Data Bank that is no more than six months old;

9.        If the applicant has never been licensed to practice in any jurisdiction or has been practicing for less than six months, a letter of endorsement from the dental, dental hygiene, or denturist school from which the applicant graduated that confirms the applicant’s graduation;

10.     If the applicant is in the military or employed by the United States government, a letter of endorsement from the applicant’s commanding officer or  supervisor that confirms the applicant’s military service or United States government employment record; and

11.     The jurisprudence examination fee.

B.       The Board may request that an applicant provide:

1.        An official copy of the applicant’s dental, dental hygiene, or denturist school diploma,

2.        A copy of a certified document that indicates the reason for a name change if the applicant’s application contains different names,

3.        Written verification of the applicant’s work history, and

4.        A copy of a high school diploma or equivalent certificate.

C.      An applicant shall pass the Arizona jurisprudence examina- tion.

Historical Note

Former Rule 3A; Former Section R4-11-29 repealed, new Section R4-11-29 adopted effective April 27, 1977 (Supp. 77-2). Former Section R4-11-29 renumbered as Section R4-11-301 without change effective July 29, 1981 (Supp. 81-4). Former Section R4-11-301 repealed, new Section R4-11-301 renumbered from R4-11-201 and amended by final rulemaking at 5 A.A.R. 580, effective February 4, 1999 (Supp. 99-1). Section amended by final rulemaking at 11 A.A.R. 793, effective April 2, 2005 (Supp. 05-1).