North Carolina Administrative Code › Title 21 - OCCUPATIONAL LICENSING BOARDS AND COMMISSIONS › Chapter 16 - DENTAL EXAMINERS › Subchapter B - LICENSURE DENTISTS › Section .0300 - APPLICATION FOR LICENSURE › Section 16B .0301 - APPLICATION FOR LICENSURE

Current through Register Vol. 39, No. 2, July 15, 2024
(a) All
				  applications for licensure as a dentist shall be made on the forms furnished by
				  the Board at www.ncdentalboard.org and shall include the following information:
(1) full name;
(2) street address as of the date of the
				  application;
(3) permanent street
				  address;
(4) preferred mailing
				  address for all information;
(5)
				  telephone number;
(6) email
				  address;
(7) age;
(8) date of birth;
(9) place of birth;
(10) citizenship or immigration status, with
				  verifying documentation;
(11)
				  social security number;
(12)
				  marital status;
(13) any other name
				  by which the applicant was known in the past, accompanied by a certified copy
				  of a court order of name change, if applicable;
(14) all resident addresses for the 10 years
				  preceding the date of application;
(15) the names, addresses, and phone numbers
				  for two individuals to whom the applicant always provides the applicant's
				  current address;
(16) disclosure
				  and explanation of any bankruptcy proceedings in which the applicant was a
				  named party;
(17) the license
				  number, issuing state, and expiration date for all current drivers' licenses
				  held by the applicant, and the issuing state for all drivers' licenses held in
				  the past by the applicant;
(18) the
				  date of the applicant's previous application for examination by the Board, if
				  applicable;
(19) the date and type
				  of any dental permit or provisional license for which the applicant applied in
				  the past, if applicable;
(20) if
				  the applicant failed an examination administered by a dental board, the date of
				  the examination and jurisdiction of the dental board that administered the
				  examination;
(21) if any dental
				  board has refused to administer an examination to applicant, the jurisdiction
				  of the dental board that refused to administer the examination and the date of
				  the refusal;
(22) the dates upon
				  which the applicant has taken the Dental National Board Examination, the
				  location of the examination, and authorization for the Board to access the
				  examination scores;
(23) if the
				  applicant failed the Dental National Board Examination, the date of the failed
				  examination;
(24) if the applicant
				  has applied for a dental license in any other state or foreign country, the
				  date of the application and whether the license was issued to the
				  applicant;
(25) all employment held
				  by the applicant for the past 10 years other than dentistry;
(26) if the applicant was terminated from
				  employment within the past 10 years, an explanation regarding the
				  termination;
(27) all dental
				  licenses from other jurisdictions ever held by the applicant, including type of
				  licensure, license number, and dates of licensure;
(28) if the applicant has ever been suspended
				  or otherwise disqualified, or reprimanded, censured, or otherwise disciplined
				  by any licensing board, professional organization, or while the applicant was
				  holding public office, a written statement disclosing:
(A) the facts that formed the basis for the
				  discipline;
(B) the date of the
				  discipline;
(C) whether the
				  applicant appealed the discipline and the outcome of any appeal; and
(D) the name and address of the authority in
				  possession of records related to discipline;
(29) if the applicant has ever been the
				  subject of a complaint with any licensing board, professional organization, or
				  while the applicant was holding public office, a written statement disclosing:
(A) the facts that gave rise to the
				  complaint;
(B) the date of the
				  complaint;
(C) whether the
				  organization that received the complaint instituted proceedings against the
				  applicant; and
(D) the name and
				  address of the authority in possession of records related to the
				  complaint;
(30) if the
				  applicant has ever been reported to the National Practitioner Data Bank or the
				  Healthcare Integrity and Protection Data Bank, a written statement disclosing:
(A) the facts that formed the basis for the
				  report;
(B) the date of the report;
				  and
(C) the name and address of the
				  authority in possession of records related to the report;
(31) if the applicant is a diplomate,
				  board-eligible, or a declared specialist in any branch of dentistry, a
				  statement of specialty and how he or she is qualified;
(32) if the applicant has taken any
				  post-graduate training or refresher courses, other than continuing education
				  courses, since receiving his or her dental degree, a written statement of the
				  dates, locations, and names of the training or refresher courses;
(33) if the applicant has ever been dropped,
				  suspended, expelled, or disciplined by any post-secondary school or college, a
				  written statement disclosing:
(A) the facts
				  leading to the discipline;
(B) the
				  date of the discipline; and
(C) the
				  school or college issuing the discipline;
(34) if the applicant has ever been denied
				  admission to any college or post-secondary school for a reason other than
				  academic qualifications, a written statement explaining the reason for the
				  admission denial;
(35) if the
				  applicant has ever served in the armed forces of the United States or any other
				  country, a written statement explaining:
(A)
				  whether the applicant has been separated from service;
(B) the nature of the separation;
(C) if other than honorable, the
				  circumstances surrounding his or her release from service;
(D) dates of service;
(E) the facts leading to any charges or
				  complaints made or filed against the applicant while the applicant was serving
				  in the armed forces, and the outcome of the charges or complaints;
(F) the facts leading to any disciplinary
				  proceedings instituted against the applicant while serving in the armed forces,
				  and the outcome of the proceedings; and
(G) if the applicant was ever a defendant in
				  any court martial, the facts giving rise to those proceedings and the outcome
				  of the proceedings;
(36)
				  a statement of whether the applicant has registered under the Military
				  Selective Service Act;
(37) a
				  statement of whether the applicant has ever:
(A) been summoned to court or before a
				  magistrate for the violation of any law or ordinance or for the commission of
				  any felony or misdemeanor;
(B) been
				  arrested for the violation of any law or ordinance or for the commission of any
				  felony or misdemeanor;
(C) been
				  taken into custody for the violation of any law or ordinance or for the
				  commission of any felony or misdemeanor;
(D) been indicted for the violation of any
				  law or ordinance or for the commission of any felony or misdemeanor;
(E) been convicted or tried for the violation
				  of any law or ordinance or for the commission of any felony or
				  misdemeanor;
(F) been charged with
				  the violation of any law or ordinance or for the commission of any felony or
				  misdemeanor; or
(G) pleaded guilty
				  to the violation of any law or ordinance or for the commission of any felony or
				  misdemeanor;
(38) if the
				  applicant has been admitted to practice dentistry in any jurisdiction, a
				  certified statement disclosing all the dental practices at which the applicant
				  has worked from dental school graduation to the date of the application,
				  including:
(A) the dates during which the
				  applicant was employed as a dentist or engaged in practice;
(B) the addresses of offices of places at
				  which the applicant was employed or practicing, and the names and addresses of
				  all employers, partners, associates, or other dentists sharing office
				  space;
(C) whether the applicant
				  was practicing general dentistry or a specialty; and
(D) the reason for the termination of each
				  employment or period of private practice;
(39) if the applicant has ever held any other
				  health care license, a written statement disclosing:
(A) the type of license held by the
				  applicant;
(B) the dates the
				  applicant held the license; and
(C)
				  the licensing board that issued the license;
(40) if the applicant has ever held hospital
				  privileges and those privileges were suspended or revoked, a written statement
				  disclosing the date, location, and reason the privileges were suspended or
				  revoked;
(41) if the applicant has
				  ever held a federal Drug Enforcement Administration license or registration
				  number and, if that license or registration number has ever been revoked,
				  suspended, or surrendered, a written statement disclosing the date, location,
				  and reason for the revocation, suspension, or decision to surrender the license
				  or registration number;
(42) the
				  applicant's post-high school, pre-dental education, including the name and
				  location of the schools the applicant attended and the period of
				  attendance;
(43) each degree
				  conferred upon the applicant, including the date of the degree and
				  institution;
(44) copies of the
				  applicant's transcripts of undergraduate college;
(45) the name and location of each dental
				  school that the applicant attended, the period of attendance, the degree
				  conferred upon applicant, and the institution that conferred the
				  degree;
(46) a statement disclosing
				  and explaining any current condition or impairment, including substance abuse,
				  alcohol abuse, or a mental, emotional, or nervous disorder or condition, that
				  in any way affects the ability to practice dentistry. For purposes of this
				  Rule, "current" means recently enough that the condition or impairment may
				  affect the applicant's ability to function as a dentist as set out in
				  G.S.
				  90-41(a)(2) and (7). If the
				  applicant contends that the condition or impairment is reduced or ameliorated
				  because the applicant is receiving ongoing treatment or participating in a
				  monitoring or support program, the applicant may provide information regarding
				  the treatment or program, and may include any verification demonstrating that
				  the applicant has complied with all provisions and terms of any drug treatment
				  program, or impaired dentists or other impaired professionals
				  program;
(47) a photograph of the
				  applicant, taken within six months prior to the date of the
				  application;
(48) a completed
				  fingerprint record card and signed release of information form authorizing the
				  Board to request a fingerprint-based criminal history record check from the
				  North Carolina State Bureau of Investigation (SBI);
(49) a copy of an unexpired CPR certificate;
				  and
(50) if the applicant holds, or
				  has held in the past, a dental license in any other state or jurisdiction, a
				  copy of a National Practitioner Data Bank Report concerning the applicant that
				  was obtained within six months prior to the date the Report is submitted to the
				  Board.