828 IAC 1-1-2 - Application forms

Authority: IC 4-1-8-1; IC 25-14-1-13

Affected: IC 25-14-1-3; IC 25-14-1-16

Sec. 2.

(a) The applicant for licensure must complete the application on forms prescribed and provided by the board. All statements contained in the application must be verified by the applicant. The verified application, fees, and other documents that the board may require must be submitted to the board.

(b) The following proof that the applicant is a graduate of a dental school that is recognized by the board must be submitted:

(1) An official transcript showing the date the degree was conferred.

(2) An official diploma or a certificate of completion signed by the:

(A) dean of the applicant's professional school; and

(B) registrar of the university or college.

(c) Additional documents to be submitted by the applicant for a license include the following:

(1) Where the name on any document differs from the applicant's name, one (1) of the following:

(A) A notarized or certified copy of a marriage certificate.

(B) Legal proof of a name change.

(2) Two (2) recent passport-type photographs of the applicant, taken within eight (8) weeks before filing of the application.

(3) If the applicant has been convicted of a criminal offense, excluding minor traffic violations, the applicant shall submit a notarized statement detailing all criminal offenses, excluding minor traffic violations, for which the applicant has been convicted. This notarized statement must include the following:

(A) The offense of which the applicant was convicted.

(B) The court in which the applicant was convicted.

(C) The cause number under which the applicant was convicted.

(D) The penalty imposed by the court.

(4) An applicant who is now, or has been, licensed to practice any health profession in another state or Canadian province must submit verification of license status. This information must be sent by the state or province that issued the license directly to the Indiana board.

(5) An applicant who is now, or has been, licensed to practice any health profession in another state shall submit a self-query form completed by the following:

(A) The National Practitioner Data Bank (NPDB).

(B) The Healthcare Integrity and Protection Data Bank (HIPDB) data bank.

(d) All applicants must submit the applicant's United States Social Security number in order to be eligible for licensure.

Notes

828 IAC 1-1-2

State Board of Dentistry; PT 1, Rule 2; filed Aug 10, 1973, 11:00 a.m.: Rules and Regs. 1974, p. 49; filed May 16, 1977, 10:10 a.m.: Rules and Regs. 1978, p. 191; filed Oct 16, 1985, 3:57 p.m.: 9 IR 520; filed Oct 12, 1993, 5:00 p.m.: 17 IR 400; readopted filed Apr 11, 2001, 3:21 p.m.: 24 IR 2896; filed Feb 28, 2002, 3:17 p.m.: 25 IR 2239; filed Mar 23, 2006, 10:15 a.m.: 29 IR 2540; readopted filed Oct 4, 2007, 3:36 p.m.: 20071031-IR-828070047RFA; readopted filed November 25, 2013, 9:23 a.m.: 20131225-IR-828130287RFA Readopted filed 11/25/2019, 12:11 p.m.: 20191225-IR-828190173RFA