Free 42127.FH11 - Indiana

APPLICATION FOR A LICENSE TO PRACTICE DENTISTRY OR DENTAL HYGIENE
State Form 42127 (R7 / 2-06) Approved by State Board of Accounts, 2006

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INDIANA STATE BOARD OF DENTISTRY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2057 E-mail: [email protected]

* Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given. FOR AGENCY USE ONLY
Date reviewed (month, day, year) Decision Initials

FOR OFFICE USE ONLY
License / exam fee Date fee paid (month, day, year) Receipt number License number License issuance date (month, day, year) Permit fee Date fee paid (month, day, year) Receipt number Permit number Permit issuance date (month, day, year)

APPLICANT
Attach two (2) passport type quality photographs of yourself taken within the last eight weeks. Please sign each photo at the bottom. Negatives and Polaroids are not acceptable.

DO NOT WRITE ABOVE THIS LINE
APPLICANT INFORMATION
Name of applicant (last, first, middle, maiden) Address (number and street or rural route number) City, state, and ZIP code Telephone number (daytime) Date of birth (month, day, year) Place of birth E-mail address * Social Security number

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TYPE OF LICENSE
Applying for licensure by: Applying as a: Are you applying for an Intern Permit?

Endorsement
Name of school

Examination

Dentist
Location of school

Dental Hygienist

Yes

No

DEGREE GRANTED BY
Date of graduation (month, day, year)

DENTAL / DENTAL HYGIENE PROFESSIONAL EDUCATION NAME OF SCHOOL LOCATION OF SCHOOL DATES ATTENDED (month, day, year)

NAME OF SCHOOL

PRE-DENTAL / DENTAL HYGIENE EDUCATION LOCATION OF SCHOOL

DATES ATTENDED (month, day, year)

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LIST ALL PLACES OF EMPLOYMENT SINCE GRADUATION FROM DENTAL / DENTAL HYGIENE SCHOOL, INCLUDING SELF-EMPLOYMENT NAME AND ADDRESS OF EMPLOYER RESPONSIBILITIES HRS / WK DATES

EXAMINATION RECORD
National Board Exam If Yes, how many times? Date of most recent test (month, year) Date of most recent test (month, year) Date of most recent test (month, year) Where taken (state or country) Where taken (state or country) Where taken (state or country)

Yes
State Board Exam

No
If Yes, how many times?

Yes
Regional Exam

No
If Yes, which regional, how many times?

Yes

No Yes No

Do you hold, or have you ever held, a license, certificate, registration or permit to practice any regulated health occupation?

LIST ALL STATES, INCLUDING INDIANA, IN WHICH YOU HAVE BEEN LICENSED TO PRACTICE ANY REGULATED HEALTH OCCUPATION. TYPE OF LICENSE STATE NUMBER DATE ISSUED CURRENT STATUS

If your answer is "Yes" to any of the following, explain fully in a sworn affidavit, including all related details. Describe the event including location, date and disposition. If malpractice, provide name of plantiff. Falsification of any of the following is grounds for permanent revocation of a license or permit issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit that you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice dentistry/dental hygiene or any regulated health occupation in any state (including Indiana) or country? 3. Are you now, or have you ever been treated for drug or alcohol abuse? 4. Have you ever been convicted of, pled guilty or nolo contendre to: A. A violation of any Federal, State or local law relating to the use, manufacturing, distribution or dispensing of controlled substances? B. Any offense, misdemeanor or felony in any state? (Except for minor violations of traffic laws resulting in fines) 5. Have you ever been denied staff membership or privileges in any hospital or health care facility or had such membership or privileges revoked, suspended or subjected to any restriction, probation or other type of discipline or limitations? 6. Have you ever been admonished, censured, reprimanded or requested to withdraw, resign or retire from any hospital or health care facility in which you have trained, held staff membership or privileges or acted as a consultant? 7. Have you ever had a malpractice judgment against you or settled any malpractice action? Yes Yes Yes No No No

Yes Yes Yes Yes Yes

No No No No No

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VERIFICATION OF EMPLOYMENT OR RESIDENCY FOR A DENTAL OR DENTAL HYGIENE INTERN PERMIT
INSTRUCTIONS: Return completed form to: INDIANA STATE BOARD OF DENTISTRY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2057 PRACTICE MAY NOT BEGIN UNTIL THE PERMIT IS ISSUED BY THE BOARD. PERMITS ARE VALID FOR A PERIOD OF ONE YEAR. * Your Social Security number is requested by this agency in accordance with IC 4-1-8-1, and it is mandatory that it be given. THIS SECTION TO BE COMPLETED BY THE APPLICANT
Name of applicant (last, first, middle, maiden) Address (number and street or rural route) City * Social Security number State ZIP code

I hereby authorize

, to furnish the ProfessionalLicensing Agency with the information below.

Signature of applicant

Date (month, day, year)

THIS SECTION TO BE COMPLETED BY THE SUPERVISING DENTIST
Name of employer Name of department (if any) Address of facility (number and street or rural route, city, state, and ZIP code) Date of employment / Residency begins (month, day, year) Briefly describe duties of applicant Date of employment / Residency ends (month, day, year) Title E-mail address Telephone number

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Position to be held by applicant

AFFIRMATION OF SUPERVISING DENTIST I hereby swear or affirm under the penalties of perjury that the information provided herein is true and correct.
Printed name Name of firm or business Address of firm or business (number and street or rural route, city, state, and ZIP code) Original signature of supervising dentist Date (month, day, year) Telephone number Title

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Insert of SF 42127

APPLICATION AFFIRMATION I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency any files, documents, records or other information pertaining to the undersigned requested by the Agency, or any of its authorized representatives in connection with processing my application for a license to practice dentistry or dental hygiene or for an intern permit. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency to disclose to the aforementioned organizations, persons, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the orginal.

AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date (month, day, year)

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