North Carolina Administrative Code › Title 21 - OCCUPATIONAL LICENSING BOARDS AND COMMISSIONS › Chapter 16 - DENTAL EXAMINERS › Subchapter B - LICENSURE DENTISTS › Section .0800 - SPECIAL RESTRICTED LICENSES › Section 16B .0801 - TEMPORARY VOLUNTEER DENTAL PERMIT

Current through Register Vol. 39, No. 2, July 15, 2024
(a) An
				  applicant for a temporary volunteer dental permit shall submit to the Board an
				  application form provided by the Board at www.ncdentalboard.org that includes
				  the following information:
(1) full
				  name;
(2) street address;
(3) employer name and address, and the
				  applicant's position title;
(4)
				  work, home, and cellular telephone numbers;
(5) fax number;
(6) email address;
(7) any other name by which the applicant was
				  known in the past;
(8) social
				  security number;
(9) citizenship or
				  immigration status, with verifying documentation;
(10) authorization to work in the United
				  States;
(11) dental education,
				  including dental school name, address, and the applicant's graduation date, and
				  any other dental post-graduate education;
(12) all dental licenses from other states
				  ever held by the applicant, including state, license number, date issued, and
				  licensure status as of the application date;
(13) if the applicant has ever been denied a
				  license or the privilege of taking a dental licensure or competency examination
				  by any dental licensing authority or examining body, a written statement
				  disclosing the details, jurisdiction, and date;
(14) if the applicant is not engaged in the
				  practice of dentistry as of the application date, the last month and year when
				  the applicant practiced;
(15) if
				  the applicant has been charged with or convicted of any crime within the 10
				  years preceding the application date, excluding traffic violations but
				  including driving while impaired offenses, a written statement disclosing the
				  details and copies of the charges and judgment;
(16) if the applicant has any contagious or
				  infectious disease, a written statement disclosing the details;
(17) 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 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;
(18) the type of facility
				  and addresses of all facilities where the applicant will provide temporary
				  volunteer dental services in North Carolina;
(19) the dates on which the applicant intends
				  to provide temporary volunteer dental services in North Carolina;
(20) the names of all North Carolina licensed
				  dentists who will direct or supervise the applicant at each location where the
				  applicant will provide temporary volunteer dental services;
(21) a copy of an unexpired CPR
				  certificate;
(22) a photograph of
				  the applicant taken within six months preceding the application date;
(23) 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); and
(24) a signed, notarized statement by the
				  applicant affirming the applicant has not been disciplined by any dental board
				  or agency, the information in the application is accurate, and no fee will be
				  charged or accepted for any dental services provided.