21 N.C. Admin. Code 16A .0106 - PETITION FOR PREDETERMINATION

An individual who wishes to file a petition for a predetermination of whether the individual's criminal history will likely disqualify the individual from obtaining a dental license or dental hygiene license shall submit a petition on the forms furnished by the Board at www.ncdentalboard.org that shall include the petitioner's:

(1) legal name;

(2) mailing, physical, and email addresses;

(3) social security number;

(4) date of birth;

(5) telephone number;

(6) place(s) of residence for the past seven years;

(7) employment history since the commission of the crime(s);

(8) criminal record report prepared no more than 60 days prior to the date of petition by Castle Branch, Inc., or another reporting service designated by the Board in accordance with G.S. 93B-8.1(b6), the cost of which shall be borne by the petitioner;

(9) copies of all documents in the court file related to any conviction reported on the petition or noted on the criminal record report, certified by the clerk of court or other judicial official;

(10) written statement describing the circumstances surrounding the commission of the crimes;

(11) written statement of any rehabilitation efforts, if applicable;

(12) rehabilitative drug or alcohol treatments, if applicable;

(13) Certificate of Relief granted pursuant to G.S. 15A-173.2, if applicable;

(14) affidavits or other written documents, including character references, that the petitioner wishes the Board to consider in responding to the petition;

(15) written statement certifying that the information and documentation submitted with the petition is complete and accurate to the best of the petitioner's knowledge;

(16) fee of forty-five dollars ($45.00) for a petition for predetermination; and

(17) notarized signature.

Notes

21 N.C. Admin. Code 16A .0106

Authority G.S. 90-29; 90-30; 90-41; 90-48; 90-223; 90-224; 90-229; 93B-8.1;
Eff. April 1, 2020.

Adopted by North Carolina Register Volume 34, Issue 21, May 1, 2020 effective 4/1/2020.