Oklahoma Board of Dentistry

Transcription

1 Susan Rogers, Esq. Executive Director Mary Fallin Governor Oklahoma Board of Dentistry HYGIENE APPLICATIONS BY EXAM APPLICATION PROCESS: 1. Submit a completed application; include the non-refundable fee and all required documentation. Make sure that you have a legible current address listed on your application. 2. Applications must be completed and submitted 30 days prior to each Board meeting. The next Board meeting is scheduled for April 25, If your application is not received 30 days prior to the Board meeting you will be on the next Board agenda which is scheduled for June 20, Your name will be placed on the Board agenda. You do not need to be present. After your application is approved, you will be notified of the date scheduled for the Jurisprudence Exam. The exam will be given at our office located at 2920 N. Lincoln Blvd, Ste B, OKC, OK After your exam is given you will be notified by mail of the results. If you have passed the exam your license for the current year will be included. If you fail the exam, instructions will be given. 5. Study material is located on our website ( under the Statutes and Rules tab. 6. Wall licenses are signed by each Board member. If a Board member is not present to sign your license it will be signed at the next Board meeting. 1

2 STATE OF OKLAHOMA BOARD OF DENTISTRY Hygienists who receive their education in another State Local Anesthesia and Nitrous Oxide Graduating from an accredited Hygiene School in a State other than Oklahoma does not automatically make you eligible to received local anesthesia and nitrous oxide. You will need to do the following: A. Contact the Oklahoma Dental Foundation at B. Sign up for the Local Anesthesia and the Administration of Nitrous Oxide courses. Completion of the Local Anesthesia Course Instructions A. Upon completion of your local anesthesia course take the letter you received from the ODF showing successful completion of your course to your employing dentist who holds and Oklahoma license. B. You will then need complete 10 blocks with your Oklahoma licensed dentist at his place of employment in Oklahoma. C. Once you have completed the 10 blocks, your employing dentist will need to write a letter to the Oklahoma Board of Dentistry confirming successful completion. D. Your license will be reprinted for that current year reflecting the ability to administer Local Anesthesia. Completion of the Administration of Nitrous Oxide A. Upon completion of your nitrous oxide course the ODF will notify our office. B. Your license will be reprinted reflecting the ability to administer Nitrous Oxide. 2

3 PHOTOGRAPH OF APPLICANT Attach a current 2x2 color photograph of applicant BOARD OF DENTISTRY STATE OF OKLAHOMA 2920 N. Lincoln Blvd., Suite B Oklahoma City, OK (405) FOR OFFICE USE ONLY Date Received Date Completed Jurisprudence Exam Taken License number issued APPLICATION FOR EXAMINATION TO PRACTICE DENTAL HYGIENE Examination Fee $100 (non-refundable) Applicants Social Security Number Date Each question must be answered fully, truthfully and accurately. All supporting data required must be received before you can take the Jurisprudence Exam. If the space provided for any question is insufficient, the applicant must complete the answer on a rider signed by him or her. Specify the number of the question to which it relates and enclose with this application. I hereby make application for the examination for issuance to me a license to practice Dental Hygiene in the State of Oklahoma, all in accordance with and subject to the rules and regulations of the Board of Dentistry and the law governing to practice of Dental Hygiene in Oklahoma. 1. Last Name in Full First Name in Full Middle Name in Full Name of Spouse if any Contact Phone Number 2. Current Resident Address City State Zip Oklahoma Resident Address City State Zip Address 4. Cell Phone Number Home Phone Number Work Phone Number 5. List any other names in full by which you have been known, the reason therefor, and inclusive dates so known. 6. / If a married woman, give maiden name. If a name change was made by court order, enclose a Certified Copy. 7. / Month Day Year Place of Birth-Must include a copy of birth certificate. Date of Birth 8. ft inches/ lbs/ / / / Height Weight Sex Race Hair Color Eye Color 9. Identifying Marks 3

4 10. EDUCATION-HIGH SCHOOL From To School Location 1 st year 2 nd year 3 rd year 4 th year GENERAL COLLEGE From To School Location 1 st year 2 nd year 3 rd year 4 th year DENTAL HYGIENE From To School Location 1 st year 2 nd year 3 rd year 4 th year I was a graduate from Hygiene School I graduated Hygiene school in the month, day and year of I belong to the following professional societies and organizations 11. NATIONAL BOARDS I have passed the National Board Examination Yes No Date I have requested that my National Board Examination be sent directly to the Oklahoma Board of Dentistry I have requested that my a Certified Copy of my National Board Examination be sent directly to the Oklahoma Board of Dentistry 12. CLINICAL EXAMINATION I have passed the Western Regional Examination Board Yes No Examination Site Date 13. OTHER STATE LICENSURE I have been or am licensed to practice Dental Hygiene in the following states and no others: State Licensed License # Type of License Date Issued Expiration License is active with this State Yes/No Years in Practice 14. I have been refused a Hygiene license in the following states and no others: Reason I have failed a Dental Hygiene examination in the following state and no others: 4

5 15. EMPLOYMENT HISTORY List all employment, temporary, part-time for the last 10 years (attached additional page if needed). Places of employment Addresses Dates: From-To Nature of Practice Reason for Leaving 16. Answer all of the following questions fully and truthfully. Attach explanations if you answer yes to any questions. Have you ever been reprimanded, had your license suspended, cancelled or revoked by any board? If yes, where when explanation attached Have you ever been the subject of an investigation by a state board? If yes, where when explanation attached Have you ever been summoned, arrested, taken into custody, indicted, convicted, tried for, charged with or plead guilty to a violation of any law or ordinance or the commission of any felony or misdemeanor, or have you been requested to appear before any prosecuting attorney or investigative agency in any manner? (Include all such incidents no matter how minor the infraction or whether guilty or not). If yes, Date State Charging Agency explanation attached Have you ever been or are you now addicted to the use of drugs, narcotics, or alcohol, in any form, or have you ever been a habitual user thereof? Have you ever had any symptoms, history or diagnosis of mental or nervous disorders, including sexual perversion, or have you ever received treatment for or had treatment recommended for any such conditions or disorders? Have you ever been refused membership in the American Dental Association or any state or local society? If yes, where when explanation attached 17. SPECIALTY TRAINING Have you completed a formal Specialty training program? What Specialty Where Date Did you graduate Date 18. OKLAHOMA EMPLOYMENT I have been offered the following position with I will begin employment on Location 19. I have requested the National Practitioner Data Bank Report be sent to the Oklahoma Board of Dentistry ( ) 5

6 BOARD OF DENTISTRY STATE OF OKLAHOMA 2920 N. Lincoln Blvd., Suite B Oklahoma City, OK CHARACTER REFERENCES Name Address Occupation Phone Name Address Occupation Phone CERTIFICATION OF DEAN OF THE HYGIENE SCHOOL CERTIFICATE OF COLLEGE GRANTING DEGREE I hereby certify that matriculated in the Hygiene School on the day of,, and attended and successfully completed a full four year course in professional hygiene comprised of four academic years or two academic years of instruction graduating or will graduate with the degree of on the day of,. I further certify that the photograph as appears in this application is the likeness of the said and the identical person to whom the said diploma was originally issued. (SEAL of College or University) SIGNATURE OF DEAN MEDICAL REPORT I, a duly licensed physician of the state of, Have this day examined, and my medical examination reveals that the applicant is not dependent on narcotic drugs or alcohol. Further, my examination reveals that the applicant does not have a communicable disease and has no physical or mental disabilities except:. The examination was made in, State of, on the day of, 20. SIGNATURE OF PHYSICIAN 6

7 BOARD OF DENTISTRY STATE OF OKLAHOMA 2920 N. Lincoln Blvd., Suite B Oklahoma City, OK THE STATE OF COUNTY OF AFFIDAVIT I,, the applicant herein, upon oath deposes and say that all facts, statements and answers contained in this application are true and correct; I am not omitting any information which might be of value to this Board in determining my qualifications and character, whether it is called for or not; and I agree that any falsification, omission, or withholding of information of facts concerning my qualifications and character, as an applicant shall be sufficient to bar me from this or any future examination given by the Oklahoma Board and such falsifications, omissions, or withholding shall serve as sufficient grounds for the suspension, cancellation or revocation of my Oklahoma Dental Hygiene License even though it is not discovered until after issuance. The attached photograph is a true likeness of the applicant. I solemnly declare upon my honor that if granted a license to practice Dental Hygiene in Oklahoma, I will respectfully comply with any law governing the practice of Dental Hygiene in this State, and will do my best to uphold and maintain the ethics of the profession. I hereby authorize and request, every person, firm, company, corporation, governmental agency, court, association or institution having control of any documents, records and other information pertaining to me, to furnish to the board such information documents, or records or any other pertinent data, and to permit the Board or any of its agents or representatives to inspect and make copies of such documents, records, and other information. I further agree to submit to question by the Board or any member thereof, and to substantiate my statements if desired by the Board. APPLICANT S SIGNATURE NOTARY Subscribed to before me the undersigned Notary Public on this day of,. My commission expires on the day of,. SEAL NOTARY PUBLIC 7

8 AFFIDAVIT OF CITIZENSHIP All natural person fourteen (14) years of age or older and present in the United States, applying for a license with the Oklahoma Board of Dentistry are required, by the provisions of 56 O.S. Supp , to provide the Board with verification of lawful presence in the United States by executing one of the Affidavits below before notary public or other office authorized to notarize affidavits under State law. The Board s licensing offices are staffed with notaries who are available to provide notary services at no cost to applicant. STATE OF ) ) COUNTY OF ) OPTION 1 AFFIDAVIT VERIFYING LAWFUL PRESENCE IN THE UNITED STATES APPLICANT NAME I,, of lawful age, being duly sworn, upon oath states, under penalty of perjury, as follows: I am a United States Citizen Applicant s Signature Subscribed and sworn to or affirmed before me this day of,, by (Applicant) NOTARY SEAL My commission expires: STATE OF ) ) COUNTY OF ) OPTION 2 AFFIDAVIT VERIFYING QUALIFIED ALIEN STATES APPLICANT NAME I,, of lawful age, being duly sworn, upon oath states, under penalty of perjury, as follows: I am a qualified alien under the Federal Immigration and Naturalization Act, and I am lawfully present in the United States Citizen Applicant s Signature Subscribed and sworn to or affirmed before me this day of,, by (Applicant) NOTARY SEAL My commission expires: 8