California Code of Regulations › Title 16 - Professional and Vocational Regulations › Division 10 - Dental Board of California › Chapter 2 - Dentists › Article 2 - Application for Licensure › Section 1028 - Application for Licensure

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a)
				  An applicant for licensure as a dentist shall submit an "Application for
				  Licensure to Practice Dentistry" (WREB) Form 33A-22W (Revised 11/06), which is
				  hereby incorporated by reference, or "Application for Determination of
				  Licensure Eligibility (Portfolio)" Form 33A-22P (New 11/2014), which are hereby
				  incorporated by reference,
(b)
				  Applications for licensure shall be accompanied by the following information
				  and fees:
(1) The application and
				  examination(s) fees as set by Section
				  1021;
(2) Satisfactory evidence that the applicant
				  has met all applicable requirements in Sections
				  1628 and
				  1632 of the Code;
(3) The applicant shall furnish two
				  classifiable sets of fingerprints or submit a Live Scan inquiry to establish
				  the identity of the applicant and to permit the Board to conduct a criminal
				  history record check. The applicant shall pay any costs for furnishing the
				  fingerprints and conducting the criminal history record check;
(4) Where applicable, a record of any
				  previous dental practice and certification of license status in each state or
				  jurisdiction in which licensure as a dentist has been attained;
(5) Applicant's name, social security number,
				  address of residency, mailing address if different from address of residency,
				  date of birth, telephone number, and gender of applicant;
(6) Information as to whether the applicant
				  has ever taken the California Law and Ethics written examination;
(7) Any request for accommodation pursuant to
				  the Americans with Disabilities Act;
(8) A 2-inch by 2-inch passport style
				  photograph of the applicant, submitted with the "Application for Licensure to
				  Practice Dentistry (WREB)" Form 33A-22W (Revised 11/06), or "Application for
				  Determination of Licensure Eligibility (Portfolio)" Form 33A-22P (New
				  11/2014);
(9) Information regarding
				  applicant's education including dental education and postgraduate study, if
				  applicable;
(10) Certification from
				  the dean of the qualifying dental school attended by the applicant to certify
				  the date the applicant graduated;
(11) Information regarding whether the
				  applicant has any pending or had in the past any charges filed against a dental
				  license or other healing arts license;
(12) Information regarding any prior
				  disciplinary action(s) taken against the applicant regarding any dental license
				  or other healing arts license held by the applicant including actions by the
				  United States Military, United States Public Health Service or other federal
				  government entity. "Disciplinary action" includes, but is not limited to,
				  suspension, revocation, probation, confidential discipline, consent order,
				  letter of reprimand or warning, or any other restriction or action taken
				  against a dental license. If an applicant answers "yes", he or she shall
				  provide the date of the effective date of disciplinary action, the state where
				  the discipline occurred, the date(s), charges convicted of, disposition and any
				  other information requested by the board;
(13) Information as to whether the applicant
				  is currently the subject of any pending investigation by any governmental
				  entity. If the applicant answers "yes," he or she shall provide any additional
				  information requested by the board;
(14) Information regarding any instances in
				  which the applicant was denied a dental license, denied permission to practice
				  dentistry, or denied permission to take a dental board examination. If the
				  applicant answers "yes", he or she shall provide the state or country where the
				  denial took place, the date of the denial, the reason for denial, and any other
				  information requested by the board;
(15) Information as to whether the applicant
				  has ever surrendered a license to practice dentistry in another state or
				  country. If the applicant answers "yes," additional information shall be
				  provided including state or country of surrender, date of surrender, reason for
				  surrender, and any other information requested by the board;
(16) Information as to whether the applicant
				  is in default on a United States Department of Health and Human Services
				  education loan pursuant to Section
				  685 of the Code; and
(17) A certification, under the penalty of
				  perjury, by the applicant that the information on the application is true and
				  correct.