SECTION .0300 - APPLICATION FOR LICENSURE

21 NCAC 16B .0301          APPLICATION FOR LICENSURE

(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.

(b)  The applicant shall submit to the Board the notarized application form with all the information and materials listed in Paragraph (a) of this Rule, accompanied by the nonrefundable application fee set forth in 21 NCAC 16M .0101.

(c)  In addition to the requirements of Paragraphs (a) and (b) of this Rule, the applicant shall request the applicable entity to send the following required information or documents to the Board office, with each document in an unopened envelope sealed by the entity involved:

(1)           the applicant's official transcripts from a dental school accredited by the Commission on Dental Accreditation of the American Dental Association;

(2)           if the applicant is licensed in other states, a certificate of the applicant's licensure status from the dental regulatory authority or other occupational or professional regulatory authority, accompanied by a disclosure of any disciplinary action taken or investigation pending, from all licensing jurisdictions where the applicant holds or has ever held a dental license or other occupational or professional license; and

(3)           examination scores required by Rule .0303(b) of this Subchapter that shall include the American Board of Dental Examiners (ADEX) dental licensure examinations.

(d)  The Board shall receive all information and documentation set forth in Paragraphs (a) through (c) of this Rule and the applicant's passing scores on all examinations required by Rule .0303 of this Subchapter for the application to be complete. Applications that are not completed within one year of being submitted to the Board shall be disregarded as expired without a refund of the application fee.

(e)  Any applicant who changes his or her address shall notify the Board office in writing within 10 business days.

(f)  Any license obtained through fraud or by any false representation shall be revoked.

History Note:        Authority G.S. 90-28; 90-30; 90-39; 90-41; 90-48;

Eff. September 3, 1976;

Readopted Eff. September 26, 1977;

Amended Eff. September 1, 2014; March 1, 2006;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018;

Amended Eff. March 1, 2020.