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Dentist - Application Forms

Application for Licensure 
Form # Title/Description
512  Application for Dental License
2252Convictions and Pending Charges
2829 Malpractice Suits or Claims Form (If applicable)
1471  Dentist Certificate of Professional Education (This form must be completed by your school and returned directly to the Department)
3071Fax Payment Form
 
Application  for Certificate to Administer Anesthesia/Conscious Sedation
Form # Title/Description
2759 Application For Dental Permit to Administer Conscious Sedation 
2758  Conscious Sedation Provider School Verification Form (This form is for course providers to verify courses already approved)
2763  Procedure for Reporting Adverse Occurrences Related to Anesthesia Administration
2764  Report of Adverse Occurrences Related to Anesthesia Administration 
3071Fax Payment Form
 
Application for Faculty License
Form # Title/Description
2650  Application For Dental Faculty License
2252 Convictions and Pending Charges
2829Malpractice Suits or Claims Form (If applicable)
3071 Fax Payment Form
 
Application for Temporary Permit to Practice Dentistry Without Compensation
Form # Title/Description
2850  Application for Temporary Permit to Practice Dentistry Without Compensation
2252 Convictions and Pending Charges
2829Malpractice Suits or Claims Form (If applicable)
3071 Fax Payment Form
 
Profession Forms
Form # Title/Description
1817  Documentation of Training Delegable Procedures to Unlicensed Person (Dental Assistant Delegation Form)

Other Information/Forms

Dentist - License Information