Applications & Forms

Applications and forms are PDF files and require Adobe Reader. For best accessibility download the current Adobe Reader.

Online Applications

• Dentist *APPLY ONLINE*
  • Application Checklist (PDF)
• Resident Dentist *APPLY ONLINE*
  • Application Checklist (PDF)
• Dental Hygienist *APPLY ONLINE*
  • Application Checklist (PDF)
• Dental Hygiene Authorities *APPLY ONLINE*
  • Application Checklist (PDF)
    • Dental Therapist/Provisional Dental Therapist
• Independent Practice Dental Hygienist
• Public Health Dental Hygienist
• Nitrous Oxide Analgesia
• Local Anesthesia
• Denturist *APPLY ONLINE*
  • Application Checklist (PDF)
• Dental Radiographer *APPLY ONLINE*
  • Application Checklist (PDF)
• Expanded Function Dental Assistant *APPLY ONLINE*
  • Application Checklist (PDF)
• Faculty License (Dentist, Dental Hygienist and Denturist) *APPLY ONLINE*
  • Application Checklist (PDF)
• Limited Dentist License *APPLY ONLINE*
  • Application Checklist (PDF)
• Temporary License (Dentist and Dental Hygienist) *APPLY ONLINE*
  • Application Checklist (PDF)

Online Applications - Sedation/Anesthesia

• Moderate Level I (Enteral) and Level II (Parenteral) Permit *APPLY ONLINE*
  • Application Checklist (PDF)
• Deep Sedation/General Anesthesia Permit *APPLY ONLINE*
  • Application Checklist (PDF)
• Itinerant Dentist Permit *APPLY ONLINE*
  • Application Checklist (PDF)
• 14 Day Notification Form *APPLY ONLINE*
  • Application Checklist (PDF)

Paper Applications

• Sedation Applications and Forms
  • Sedation Registration (PDF)
• Denturist Trainee Registration (PDF)
  • Denturist Trainee Supervision Form (PDF)

Sedation/Anesthesia Forms

• Certification Form - Moderate Sedation (PDF)
• Certification Form - Deep Sedation/General Anesthesia (PDF)

Board Approved Programs and Licensure Examinations

• Dentist
• Denturist (Examinations)
• Denturist (Programs)
• Dental Hygienist and Dental Hygiene Practice Authorities
• Dental Radiography
• Expanded Function Dental Assistant

Education and Program Completion Forms

• Certificate of Education Form (PDF)
• Certificate of Denturism Program Completion Form (PDF)
• Certificate of EFDA Training/Program Completion Form (PDF)
• Certificate of Program/Course Completion Form (PDF)

Clinical Practice and Supervision Forms

• Dental Therapy Agreement Outline (PDF)
• Provisional Dental Therapy Agreement Outline (PDF)
• Dental Therapy Verification of Clinical Practice (PDF)
• IPDH Clinical Practice Verification (PDF)
• Residency Program and Supervision Form (PDF)

Continuing Education Forms

• Continuing Education Log (PDF)
• CE Provider Pre-Approval Form (PDF)

Other Forms

• Credit Card Authorization Form (PDF)
• Data Request Form (PDF)
• Social Security Number Affidavit

If you cannot find what you are looking for, send an email to the Board of Dental Practice.