Application for limited license to practice dentistry



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Maryland State Board of Dental Examiners

Spring Grove Hospital Center  Benjamin Rush Building

55 Wade Avenue Tulip Drive

Catonsville, Maryland 21228

(410) 402-8511

APPLICATION FOR LIMITED LICENSE TO PRACTICE DENTISTRY

FOR GRADUATES OF DENTAL SCHOOLS OUTSIDE THE U.S OR CANADA
Notice For Mailing List:

The information collected on this application form is collected for the purposes of the Board’s functions under the Annotated Code of MD, Health Occupations Article, Title 4. Failure to provide the information may result in denial of your application. You have a right to inspect, amend, and request correction of this information. The Board may permit inspection of this information or make it available to others only as permitted by federal and State law. Under the Maryland Public Information Act, Annotated Code of Maryland, General Provisions Article, §4-333, the Board may provide, for a fee, a list of licensees’ names and addresses to professional associations and other entities. You may request in writing that your name be omitted from such lists.


Information for Veterans, Service Members, and Military Spouses
Please note the following:
“Veteran” is a former service member who was discharged from active duty under circumstances other than dishonorable within 1 (one) year before the date on which this application has been submitted. “Veteran” does not include an individual who has completed active duty and has been discharged for more than 1 year before the application for a license, certificate, or permit is submitted.
“Service member” is a an individual who is an active duty member of the armed forces of the United States, a reserve component of the armed forces of the United States, or the National Guard of any state.
“Military Spouse” is the spouse of a service member or veteran and includes the surviving spouse of a veteran, or a service member who died within 1 (one) year before the date on which the application for licensure is submitted to the Board.
Veterans, service members and military spouses are assigned an advisor to assist in the application process. In addition, the Board will expedite the processing of completed applications for veterans, service members, and military spouses. If you do not meet the education or training or experience requirements for licensure, your advisor will assist you in identifying programs that offer relevant education or training, or ways to obtain the necessary experience.
Your advisor is Deborah Welch. Ms. Welch may be reached at 410-402-8511. In Ms. Welch’s absence you may contact Ms. Sandra Sage at 410-402-8510.
Are you a:
Veteran  Yes  No Service Member  Yes  No Military Spouse  Yes  No

SECTION I – GENERAL INFORMATION

Name

(Last, First, Middle Initial):




Address of Record:

(Street Address)




City, State, Zip:





APPLICATION FEE – MADE PAYABLE TO THE MARYLAND STATE BOARD OF DENTAL EXAMINERS

Limited License: $300


A. Social Security Number:    -   -    

(There is a statutory requirement that you disclose your social security number. It will be used for identification purposes only.)


B. Date of Birth:   -   -    
C. Home Phone Number:    -    -    
D. Work Phone Number:    -    -    
E. E-Mail Address:
F. Gender:  Female  Male

Are you of Hispanic or Latino origin? Yes  No 

(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)



G. Race/Ethnic Identification – Please check all that apply

Select one or more of the following racial categories:


1.  American Indian or Alaska Native (A person having origins in any of the original peoples of North or

South America, including Central America, and who maintains tribal affiliations or community attachment.)


2.  Asian (A person having origin in any of the original peoples of the Far East, Southeast Asia, or the Indian

subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)


3.  Black or African American (A person having origins in any of the black racial groups of Africa.)
4.  Native Hawaiian or other Pacific Islander (A person having origins in the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
5.  White (A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.)
H. Licensure in other states:

List other states or jurisdiction in which you hold or have held a dental license. Include license number(s).




State

License Number





















SECTION II - EDUCATION
A. School of Graduation (DDS, DMD, or equivalent) (Name, City, State, Country):

______________________________________________________________________________________
B. Date of Graduation: ___________________ Degree Earned: _____________________________
C. College or University of Formal General Clinical Training (U.S. or Canada):

_____________________________________________________________________________________
D. Dates Attended: ______________________

SECTION III - CHARACTER AND FITNESS
If you answer “YES” to any question(s) in Section III – Character and Fitness, attach a separate page with a complete explanation of each occasion. Each attachment must have your name in print, signature, and date.

YES NO


  a. Has any licensing or disciplinary board of any jurisdiction, including Maryland, or any federal entity denied your application for licensure, reinstatement, or renewal, or taken any action against your license, including but not limited to reprimand, suspension, revocation, a fine, or non-judicial punishment? If you are under a Board Order or were ever under a Board Order in a state other than Maryland you must enclose a certified legible copy of the entire Order with this application.
SECTION III - CHARACTER AND FITNESS (CONT’D)

YES NO


  b. Have any investigations or charges been brought against you or are any currently pending in any jurisdiction, including Maryland, by any licensing or disciplinary board or any federal or state entity?
  c. Has your application for a dental hygiene license in any jurisdiction been withdrawn for any reason?
  d. Has an investigation or charge been brought against you by a hospital, related institution, or alternative health care system?
  e. Have you had any denial of application for privileges, failure to renew your privileges, or limitation, restriction, suspension, revocation or loss in privileges in a hospital, related health care facility, or alternative health care system?
  f. Have you pled guilty, nolo contendere, had a conviction or receipt of probation before judgment or other diversionary disposition of any criminal act, excluding minor traffic violations?
  g. Have you pled guilty, nolo contendere, had a conviction, or receipt of probation before judgment or other diversionary disposition for an alcohol or controlled dangerous substance offense, including but not limited to driving while under the influence of alcohol or controlled dangerous substances?
  h. Do you have criminal charges pending against you in any court of law, excluding minor traffic violations?
  i. Do you have a physical condition that impairs your ability to practice dental hygiene?
  j. Do you have a mental health condition that impairs your ability to practice dental hygiene?
  k. Have the use of drugs and/or alcohol resulted in an impairment of your ability to practice dental hygiene?
  l. Have you illegally used drugs?
  m. Have you surrendered or allowed your license to lapse while under investigation by any licensing or disciplinary board of any jurisdiction, including Maryland, or any federal or state entity?
  n. Have you been named as a defendant in a filing or settlement of a malpractice action?
  o. Has your employment been affected or have you voluntarily resigned from any employment, in any setting, or

have you been terminated or suspended, from any hospital, related health care or other institution, or any federal

entity for any disciplinary reasons or while under investigation for disciplinary reasons?

The Well Being Committee assists dentists and their families who are experiencing personal problems. The Committee has helped

many dentists over the years with problems such as stress, drug dependence, alcoholism, depression, medical problems, infectious

diseases, neurological disorders and other illnesses that cause impairment. For more information, dentists may visit

www.dentistwellbeing.com.

Incomplete applications will be returned and will be subject to a $50.00 application reprocessing fee.

SECTION IV – FACILITY
A. Location where applicant will practice: (name and address)


Notice for Mailing List:

The information collected on this application form is collected for the purposes of the Board’s functions under the Annotated Code of MD, Health Occupations Article, Title 4. Failure to provide the information may result in denial of your application. You have a right to inspect, amend, and request correction of this information. The Board may permit inspection of this information or make it available to others only as permitted by federal and State law. Under the Maryland Public Information Act, the Annotated Code of MD, State Government Article, §10-617, the Board may provide, for a fee, a list of licensees’ names and addresses to professional associations and other entities. You may request in writing that your name be omitted from such lists.


Applicant Signature

I hereby affirm that I have read and followed the above instructions. I hereby certify that all information in this application is accurate and correct.


_________________________________________________________________ _______________________________

Applicant Signature Date


NOTARY SECTION
State of ___________________, County of _________________, then personally appeared the above named
______________________________________, and signed and sworn to the truth of the foregoing statements in my

presence.


Notary Public: __________________________ My Commission Expires: __________________

SEAL

MARYLAND STATE BOARD OF DENTAL EXAMINERS


Application for Limited License to Practice Dentistry for

Graduates of Schools Outside the U.S. or Canada

CHECK LIST



Please review prior to sending your application package to the Board.
Incomplete applications will be returned and will be subject to a $50.00 application reprocessing fee.
ALL CANDIDATES
 1. Is your application completed front and back?


  • Did you sign and have the application notarized?

 2. Have you enclosed a written request from the hospital, sanitarium, or dental school to which the license to

practice dentistry is to be limited?
 3. Have you enclosed a $300 non-refundable fee made payable to the Maryland State Board

of Dental Examiners?


 4. Did you enclose one photo that is between 2x2-inches and 3x3-inches with the required notarized

affidavit? Note that the photo will be affixed to your license. The photo must meet the following

guidelines: taken within the last 2 years to reflect your current appearance; front view of full face

from top of hair to shoulders; a natural expression; no hat; or head covering that obscures the hair

or hairline, unless worn daily for religious purposes; no sunglasses, headphones, wireless hands-free

devices or similar items; no other individuals or distractions in the photo. Photos copied or digitally

scanned from driver’s licenses or other official documents are not acceptable. In addition, low quality

vending machine or mobile phone photos are not acceptable. “Passport” photos are acceptable.

Unacceptable photos will be returned and shall delay the issuance of your license.
 5. Have you enclosed evidence satisfactory to the Board that you have completed at least 2 years of formal

general clinical training in a United States or Canadian accredited institution?


 6. Have you enclosed a copy of the degree or diploma, including an English translation (if applicable),

issued to the applicant by the foreign dental school conferring it, properly authenticated by an official of

that dental school authorized to make the authentication?
 7. Have you enclosed a copy, including an English translation (if applicable), of the subjects taken and the

credits earned at the foreign dental school, properly authenticated by an official of that foreign dental

school authorized to make the authentication?
 8. Have you enclosed a certified letter with the state seal affixed from each state in which you hold or have

ever held a license verifying that the license is or was in good standing?


 9. Have you enclosed two letters of recommendation that certify to the Board the good moral character as

well as the applicant’s age, qualifications, background, and experience, if any?


 10. Have you enclosed a letter from the hospital, sanitarium, or dental school which the

license to practice dentistry is to be limited that indicates that you possess sufficient

comprehension and communication skills in written and spoken English to enable you to

adequately treat dental patients?


 11. If applicable, have you enclosed evidence of legal name change, such as a marriage certificate or court

documents.



MARYLAND STATE BOARD OF DENTAL EXAMINERS

GUIDELINES FOR LIMITED LICENSE TO PRACTICE DENTISTRY

FOR GRADUATES OF DENTAL SCHOOLS

OUTSIDE THE UNITED STATES OR CANADA
The Board may not process a licensure application until each provision or requirement is met and each document is received. Please ensure that your application is complete before submitting it to our office.
The applicant shall:
a. Be of good moral character;
b. Be at least 21 years old;
c. Have completed at least 2 years of formal general clinical training in a college or university that is authorized by any state or any province of Canada to grant the Degree of Doctor of Dental Surgery, Doctor of Dental Medicine, or the equivalent, and is recognized by the Board.
To apply for licensure, submit the Application for a Limited License to Practice Dentistry and enclose the following with your application:


  • A written request from the hospital, sanitarium, or dental school to which the license to practice dentistry is to be limited.




  • A $300 non-refundable fee.




  • A photograph that meets the requirements contained in the Checklist with the following notarized statement:

“The picture is a true photograph of me.”


  • Evidence satisfactory to the Board that the applicant has completed at least 2 years of formal general clinical training in a United States or Canadian accredited institution. Acceptable proof includes a certified copy of a diploma, a letter from the school, or official transcripts. Please do not submit your original copy. The document must contain the raised, embossed school seal certifying its authenticity. However, letters from educational institutions on original letterhead, bearing an original signature do not require a raised, embossed school seal.




  • Proof of foreign dental education. A copy of the degree or diploma issued to the applicant by the foreign dental school conferring it, properly authenticated by an official of that dental school authorized to make the authentication. If the degree or diploma is in a language other than English, each document must be accompanied by an English translation, certified by an individual acceptable to the Board. Please contact the Board at 410-402-8511 to discuss the translator’s credentials.




  • Proof of courses taken. A copy of the subjects taken and the credits earned at the foreign dental school, properly authenticated by an official of that foreign dental school authorized to make the authentication. If the transcript is in a language other than English, each document must be accompanied by an English translation, certified by an individual acceptable to the Board. Please contact the Board at 410-402-8511 to discuss the translator’s credentials.




  • License. If applicable, a copy of a license to practice dentistry issued by the foreign country or proper subdivision of the country in which you have graduated, properly authenticated by the issuing authority.




  • A certified letter with the state seal affixed from each state in which the applicant holds or has held a license verifying that the license is or was in good standing.




  • Two letters of recommendation that certify to the Board the good moral character as well as the applicant’s age, qualifications, background, and experience, if any.




  • A letter from the hospital, sanitarium, or dental school which the license to practice dentistry is to be limited indicating that the applicant possesses sufficient comprehension and communication skills in written and spoken English to enable the applicant to adequately treat dental patients.






Incomplete applications will be returned and will be subject to a $50.00 application reprocessing fee.


PLEASE MAIL APPLICATION AND SUPPORTING DOCUMENTS TO:
Maryland State Board of Dental Examiners

Spring Grove Hospital Center

Benjamin Rush Building

55 Wade Avenue • Tulip Drive

Catonsville, MD 21228

ATTN: Licensing Unit





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