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

Current through Register Vol. 39, No. 2, July 15, 2024
(a) All
				  applications for licensure as a dental hygienist 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 past 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 hygiene 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 Hygiene National Board Examination,
				  the location of each examination, and authorization for the Board to access the
				  examination scores;
(23) if the
				  applicant failed the Dental Hygiene National Board Examination, the date of the
				  examination that he or she failed;
(24) if the applicant has applied for a
				  dental hygiene 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;
(26) if the
				  applicant was terminated from employment within the past 10 years, an
				  explanation regarding the termination;
(27) all dental hygiene licenses from other
				  jurisdictions ever held by the applicant, including type of licensure, license
				  number, and dates of licensure;
(28) places of employment at which the
				  applicant has practiced dental hygiene, including the name of the employer, the
				  address of the employer, dates of employment, and the reason for leaving the
				  employment;
(29) 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;
(30) 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;
(31) 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;
(32) if the applicant has ever been dropped,
				  suspended, expelled, or disciplined by any post-secondary school or college for
				  any cause, 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;
(33) 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;
(34) 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 up
				  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 the
				  applicant was 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;
(35) a statement of whether the applicant has
				  registered under the Military Selective Service Act;
(36) 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;
(37) the
				  applicant's high school education including the name, location, and period of
				  attendance for each school, and the date of graduation;
(38) any college or university education
				  other than dental hygiene, including the name, location, and period of
				  attendance for each school, and the date of graduation;
(39) the applicant's dental hygiene education
				  including the name, location, and period of attendance for each school, and
				  date of graduation;
(40) 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 dental
				  hygiene. For purposes of this Rule, "current" means recently enough that the
				  condition or impairment may affect the applicant's ability to function as a
				  dental hygienist as set out in
				  G.S.
				  90-229(a)(4) and (13). 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 dental hygienists or other
				  impaired professionals program;
(41) a photograph of the applicant, taken
				  within six months prior to the date of the application;
(42) 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);
(43)
				  a copy of an unexpired CPR certificate; and
(44) if the applicant holds, or has held in
				  the past, a dental hygiene 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.