APPLICATION F'EE GENERAL INF'ORMATION LICENSURE BY EXAMINATION LICENSURE BY ENDORSEMENT CERTIFICATION

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1 NE\il HAMPSHIRE BOARD OF DENTAL EXAMINERS 12I SOUTH FRUIT STREET concord, NH (603)2714s6r InState Toll Free ' Ext HYGIENISTS GENERAL INFORMATION REQUIREMENTS FOR LICENSURE EXAMINATION or ENDORSEMENT PLEASE READ CAREF'ULLY GENERAL INF'ORMATION Each applicant for licensure practice dental hygiene in the state of New Hampshire must complete all of the information on the attached "Hygienist Apptication for Licensure" form' LICENSURE BY EXAMINATION Any person who has taken and passed the American Board of Dental Examiners (ADEX) dental hygiene examination or other similar U.S. regional or state board, including clinical procedure components, within the 3 years immediately prior submitting the application shall be considered for licensure by examination. LICENSURE BY ENDORSEMENT CERTIFICATION Any person holding a current, unsuspended, unrestricted license practice dental hygiene in ather state who has taken ahd passed the ADEX dental hygiene examination, or an examination administered by ather U.S. regional testing agency,with a passing score on each part of the examination, and practiced clinical dental hygiene in one or more states for t less than 3 years immediately prior submitting the application, shall be considered for licensure by endorsement. APPLICATION F'EE A certified check or money order in the amount of $100.00, made payable the "TREASURER' STATE OF NEW HAMPSHIRE" must accompany the application, or if presented in person, the payment may be made in cash. REOUIREMENTS FOR APPLICATION In addition the application form, the following documents shall be filed with the Board: TRANSCRIPT: An official copy of the applicant's dental hygiene school transcript, bearing the registrar's original signature and the school's seal, sent directl) by the school the New Hampshire Board of Dental Examiners' NATIONAL BOARD EXAMINATION: The applicant's original grade card, deting successful completion of the examination, sent directl) b] the National Board of Dental Examiners the New Hampshire Board of Dental Examiners. Please contact the National Board directly ( ) or write : National Board of Dental Examiners, 2ll E. Chicago Ave., Chicago IL BIRTH CERTIFICATE: An original or certified copy of the applicant's birth certificate written in English or translated English. A certified copy of the applicant's valid passport written in English or translated English may be used in place of a birth certificate.

of New Hampshire must complete all of the information on the attached "Hygienist Apptication for Licensure" form' LICENSURE BY EXAMINATION Any person who has taken and passed the American Board of

2 LETTER OF GOOD STANDING: The following documents shall be filed with the Board: A certified statement from the dental examining board of each state in which the applicant has been licensed as whether the applicant's license practice in that state, based on the records ofthe board, has been subject disciplinary action, has disciplinary action pending, has been under stayed probation, or is under investigation. This statement must be submitted directly from the dental board of each state in which the applicant has ever had a license (whether active, inactive, or lapsed). This statement shall be updated if more than 4 months old. REGIONAL BOARD SCORES: If applying for licensure by examination, the applicant shall advise the Commission on Dental Competency Assessments (CDCA) make his or her scores available the Board online. Applicants must send scores from other regional boards directly the Board's office. JURISPRUDENCE EXAMINATION After the application and all the supporting documents are received, the application file will be reviewed by the New Hampshire Board of Dental Examiners or its representative. If the file is acceptable the Board or its representative, the applicant will be tified that the application is complete and that the jurisprudence examination may be taken. The applicant shall take a test on the contents of RSA 31.7A Dental Practice Act, administrative rules Den 100 through Den 500, the American Dental Association's Principles of Ethics and Code of Professional Conduct, and the American Dental Hygienists' Association Code of Ethics for Dental Hygienists. LOCAL ANESTHESIA After vou have been licensed bv the Board of Dental Examiners and have taken a course in local anesthesia that satisfies the requirements of Den (p) and (q), you must send the following the Board obtain a local anesthesia permit: 1. A written request the Board and a $25 fee (check made payable "TreasurerState of NH") 2. Proof of course completion. 3. CDCA score. REGISTRATION A registration fee in the amount of $ is required at the time of licensure and each biennial registration thereafter. Certified checks or money orders should be made payable "TREASURER, STATE OF NE\il HAMPSHIRE." If presented in person, the payment may be made in cash, The biennial registration period commences MAY lst of oddnumbered years. Biennial registration requires that registration forms be mailed before February l5th of oddnumbered years. Licensees are required report a change of business or residential address and phone number within l0 days of any change the Board. Written tifïcation the Board is required' rf you HAVE ANy QUESTTONS OR NEED ASSTSTANCE, PLEASE CONTACT THE ADMINISTRATIVE OFFICE. PLEASE NOTB THE ADDRESS AND TELEPIIONE NUMBER ON THE FRONT SIDE OF'THIS INFOR]\{ATION SHEET.

investigation. This statement must be submitted directly from the dental board of each state in which the applicant has ever had a license (whether active, inactive, or lapsed).

3 NEW HAMPSHIRE BOARD OF DENTAL EXAMINERS DENTAL HYGIENIST APPLICATION FOR LICENSURE FOR OFFICE USE ONLY PAID $ CASH, CHECK OR MO # ExaminationÆndorsement application (circle one) practice dental hygiene False statements, kwingly made by the applicant, shall void any license issued. All questions must be completed or this application will be returned or rejected. PRINT OR TYPE 1. Name in Full (first, middle, 2. Date of Birth (month, day, year) 3. Place of Birth (city, county' state) 4. Social Security Number 5. Have you ever been kwn by any other name? name(s) 6. Current residential address: If' give other Primary address (either business or personal): Day Time Telephone Number: 7. School of Dental Hygiene Location Date of Graduation (Month' Day' ) 8. Have you taken and passed: The National Board The ADEX (written) The ADEX (clinical) Others (name) 9. Are you currentty certified in CPR? (Please provide proof.) By April 1,2016, applicants shall be certifted in basic tife support for healthcare providers (BLSHCP).

Name in Full (first, middle, 2. Date of Birth (month, day, year) 3. Place of Birth (city, county' state) 4. Social Security Number 5. Have you ever been kwn by any other name? name(s) 6.

4 Page2 10. List all places where you have possessed a license practice dental hygiene. If ne, so state: State and License No. Issue Date Active/Inactive Dates of Practice 11. Professional Employment Hisry I have been employed by the following dentists: If ne, so state. Dates Name Location 12. Have you ever been convicted of any felony, misdemear, or driving under the influence of alcohol or drugs which has t been annulled? 13. Have you ever been convicted ofthe illegal practice ofdental hygiene? 14. Have you ever been denied dental hygiene licensure? 15. Has your license practice dental hygiene ever been or are you currently subjected by a professional licensing body any investigation, sanction, or disciplinary action? This includes but is t limited revocation, suspension, probation or stayed probation, timitation or restriction, fine, reprimand, denied renewal, voluntarily or involuntarily retinquished, or being required submit care, counseling, supervision, or further education? 16. a. Do you have any physical or mental illness that impairs your ability practice dental hygiene? b. Has a health practitioner or mental health practitioner advised you that you have any physical or mental illness that impairs your ability practice dental hygiene? 17. Is your ability practice dental hygiene impaired by an addiction alcohol, narcotics, or other mind altering drugs? Yes 18. Have you ever been or are you currently named as a party in any malpractice or professional liability claim or lawsuit or is there any pending? Ifyou have answered any question, 12 through 18, attach a statement explaining the circumstances fulty.

Have you ever been convicted of any felony, misdemear, or driving under the influence of alcohol or drugs which has t been annulled? 13.

5 Page Exctuding pregraduate training, list the dentaudental hygiene continuing education courses you have taken during the last two (2) years. Ifne, so state. (Please do t attach documentation.) Date Course Location Hours STATEMENTS OF PROFESSIONAL CHARACTER (Statements from family members are t acceptable) Note: If you had previous employment as a dental hygienist, at least I of the 2 signatures should be by a licensed dentist in good standing. We, the undersigned, are personally acquainted with application, and recommend h_ as a person of good professional character., named in this Signature: Printed Name: Address: Occupation: If a dentist, License # state _ Length of time applicant kwn Signature: Printed Name: Address: Occupation: If a dentist, License # state Length of time applicant kwn

signatures should be by a licensed dentist in good standing. We, the undersigned, are personally acquainted with application, and recommend h_ as a person of good professional character.

6 Page 4 I certify that (Name of Applicant) EDUCATION REQUIREMENTS ATTACH PHOTOGRAPH has attended the required courses in the study of dental hygiene and was graduated from: (Name of Dental Hygiene School) (Date degree conferred) and the phograph attached is a likeness of (Name) (Signature of Dean, Registrar, or Secretary) (Date) Phograph must be a passport pho and t more than 6 months old. Seal of School must be impressed oyer a portion of the phograph and a portion of the application. The following affidavit must be completed by the applicant after the previous portion is filled out. I understand that by signing this application I am: STATEMENT BY APPLICANT Must te sworn befu 1. Waiving any confidentiality regarding disclosure the Board from any other jurisdiction about any pending complaints or action being taken against my license practice dental hygiene. 2. Giving consent for a criminal background check. I, of full age, under the penalties for falsification pursuant RSA 641:1 through RSA 641:3, state that I am the person referred in the foregoing application, that I have carefully read the instructions given and questions asked in the application form, and that all statements made therein are true and correct as of this (dav) of (month) 20 Signature of Applicant Sworn before me and subscribed in my presence day of 20 on this my commrssron exprres: Adopted: 12915

Seal of School must be impressed oyer a portion of the phograph and a portion of the application. The following affidavit must be completed by the applicant after the previous portion is filled out.

APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR DENTAL HYGIENE

Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR