Dental Hygiene Application Checklist

1 New Jersey office of the Attorney GeneralDivision of Consumer AffairsNew Jersey State Board of Dentistry124 Halsey Street, 6th Floor, Box 45005 Newark, New Jersey 07101(973) 504-6405 Dental Hygiene Application ChecklistThere are 3 ways to obtain a license as a Dental hygienist in the State of New Licensure by 2. past five years (If you took the more than five years ago, and are licensed in another state, you may apply by past five years. 3. Licensure by credentials (If you have a current license in another state, obtained by some other state or regional clinical examination, you may apply by Licensure by credentials. Score reports of this examination must be submitted with Application .))

2 Use this check-list to determine that you have complied with all of the requirements. Once your Application is received, a file will be established and you will be notified if any documents are missing. The Jurisprudence Exam can be taken at any time during this process. Please refer to the Jurisprudence Examination information enclosed with this packet. _____ Complete and return the Certification and Authorization Form For a Criminal History Background Check (now required by law). Instructions will be provided in a follow-up letter once your Application has been received and processed. _____ Application Fee (nonrefundable): 1. If you have taken the clinical examination please enclose a check or money order for $ 2.

3 If you are applying through reciprocity (a licensee who has taken another state or regional clinical examination currently licensed in another state or jurisdiction) please enclose a check or money order for $125. Checks should be made payable to "State of New Jersey" and sent with this Application to: NJ Board of Dentistry, Box 45005, 124 Halsey Street, 6th Floor, Newark, NJ 07101 _____ Answer all questions on the Application form. _____ Staple one passport size photograph to the front page of the Application . Please sign and print your name along with the date on the back of the photo. _____ Enter your social security number. _____ Have your Dental Hygiene school(s) provide an official school transcript in a sealed envelope.

4 DO NOT open the envelope. Attach each sealed transcript(s) with the Application , or arrange to have the school(s) forward the transcript(s) directly to the Board office . _____ Make photocopies of the State Verification Form ( ) and mail to each state in which you hold (or held) a license. Each state must fill out the form, stamp it with their official state seal and mail it directly to NJ Board of Dentistry, Box 45005, 124 Halsey Street, 6th Floor, Newark, NJ List the date that each exam was taken in the Examination History section. _____ Please provide your DENTPIN ( Dental Personal Identification Number) number so the Board may obtain your scores from the National Board Exam.

5 ALSO, CONTACT THE NATIONAL BOARD TO ELECTRONICALLY RELEASE YOUR SCORES TO THE NJ STATE Please use additional paper if you cannot fit all of your information in the space provided on this form. Make a notation by each question that more information has been attaclied. Please mark your attached answers with the same number corresponding to the question that you are answering. _____ If you have answered Yes, to any of the child support questions, please attach an explanation on a separate piece of paper to this Application form. _____ Fill out the Medical Conditions form from your packet and send back with your Application . _____ Once the entire Application has been completed, have it signed and sealed by a Notary Public.

6 Upon approval of your Application you will be notified by letter and requested to provide your initial biennial license Jersey office of the Attorney GeneralDivision of Consumer AffairsNew Jersey State Board of Dentistry124 Halsey Street, 6th Floor, Box 45005 Newark, New Jersey 07101(973) 504-6405 Application for a Dental Hygiene License Date: _____ A nonrefundable Application filing fee of $75 (or $125 if you are applying by reciprocity) in the form of a check or money order made out to the State of New Jersey, must be submitted with this Application . (Applicants should understand that if the fees are paid with a personal check, and the check is returned by the bank due to insufficient funds, the next step in the licensure process will be delayed until the fees are paid.)

7 The D ivision is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their consent. However, you are required to provide an address that may be released to the public in our directories or in response to other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of your place of residence, you should provide an address of record other than your place of residence that may be released to the public. One of your addresses must include a street, city, state and ZIP that you provide on this Application may be subject to public disclosure as required by the Open Public Records Act (OPRA).

8 Please print clearly. You must answer all of the questions on this Information Date of birth: _____ Month Day Year Name Mrs. _____ ( _____) Ms. Last name First name Middle initial Maiden name2. A ddress Home: _____ Street or Box City State ZIP code County _____ _____ Telephone number (include area code) E-mail address Business: _____ Name of company Telephone number (include area code) _____ Street City State ZIP code County Mailing: _____ Street or Box City State ZIP code CountyIn this box staple a clear, full-face passport-style photograph (2 x 2 ) of your head and shoulders, taken within the past six photo is required with each 1 -For office use onlyApplication number: _____Check or money order: _____Date processed: _____License number: _____3.

9 Social Security You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of licensure or certification. *Social Security Number: _____ - _____- _____ *Pursuant to 54:50-24 et. seq. of the New Jersey taxation law, 2 of the New Jersey Child Support Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 , and , the Board is required to obtain your Social Security number. Pursuant to these authorities, the Board is also obligated to provide your Social Security number to: a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing compliance with State tax law and updating and correcting tax records, b.

10 The Probation Division or any other agency responsible for child support enforcement, upon request, and c. the National Practitioner Data Bank and the HIP Data Bank, when reporting adverse actions relating to health care professionals. 4. Citizenship / Immigration Status Federal law limits the issuance or renewal of professional or occupational licenses or certificates to citizens or qualified aliens. To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not a citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the office of Citizenship and Immigration Services (USCIS).