​​​​​​​​​​​​​​​​​​​​​​​​​​​
Forms & Applications

 Updated on 12/12/2017
  ALL files are PDF. Download Adobe Acrobat Reader for viewing .PDF files
DENTIST
Initial Application (by NERB examination)

Download

Initial Application (Licensed in another state) Download
Initial  Limited Dental - Graduate of U.S. or Canadian Dental School Download
Initial Application for a Teacher’s License – Dentistry/ Dental Hygiene
Download​
Initial Limited Dental - Graduate of Foreign Dental School

Download

2017 Renewal Application
​Download
2017 Jurisprudence Exam Download​
Dental Pediatric Fellow Download

Dental Volunteer Application

Download

​Dentist Temporary Volunteer Application

Downloa​d
Retired Volunteer Application Download
​Ownership of a Dental Practice Download​
Application for Recognition as a Specialist

Download

​Full Drug Dispensing Permit Application Download
​Limited Drug Dispensing Permit Application Download
DENTAL HYGIENIST
Initial Application (by NERB examination)

Download

Initial Application (Licensed in another state)

Download

2017 Renewal Application

Download
2017 Jurisprudence Exam ​Download
​Dental Hygienist Volunteer Application Download
​Retired Volunteer Application Download​
Dental Hygiene Waiver of Supervision
Download
​Applicant NOT recognized to administer local anesthesia in another state Download​
Applicant recognized to administer local anesthesia in another state Download​
​Applicant NOT recognized to administer local anesthesia (BLOCK) in another state Download
Applicant recognized to administer local (BLOCK) in another state Download​
​Applicant recognized to administer Nitrous Oxide  Download​
​Applicant recognized to administer Nitrous Oxide in another state ​Download

DENTAL RADIATION TECHNOLOGIST

Initial Dental Radiation Technologist by waiver Download
Initial Dental Radiation Technologist by examination Download​​
Initial Qualified Dental Assistant- General Download
​Initial Qualified Dental Assistant- Orthodontics Download​
​Application for Reinstatement of Expired 2017 Dental Radiology Technologist Certificate- ODD Certificate Holders ONLY Download​
​Application for Reinstatement of Expired 2017 Dental Radiology Technologist Certificate- EVEN Certificate Holders ONLY Download​
​Reinstatement of a Dental Radiation Technologist Certification ​Download
SEDATION PERMITS
Renewal Application for Anesthesia and Sedation Permits and Certificates Download
​Affidavit for Class I, II and III Permit Renewal  Download
Application for Initial Anesthesia and Sedation Permits and Certificates Download
MISCELLANEOUS FORMS
Photo Affidavit- All license types Download
Change of Information (name, address, etc.) Download
Roster Request Form Download
Reactivation of an Inactive License- Dentist & Hygienist
​Download​
Reinstatement of Expired License- Dentist, Dental Hygienist, Dental Teacher
Download​
Application for Corporate Name Download
​Authorization for Use of Corporate Name Download

​​​​