FOR
OFFICE USE ONLY
CHECK
LICENSE APPLYING FOR Clinical
Board
Dental License NB LAW
Temporary permit (for public Let.
of Rec.
health service programs only) Let. of Cert.
Teaching permit (for certified FEES
institutions only)
Dental intern permits (for certified
institutions only)
WEST
VIRGINIA BOARD OF DENTAL EXAMINERS
APPLICATION
FOR EXAMINATION
In compliance with Chapter 30,
Article 4, Code of West Virginia 1931, as amended, I hereby make application to
be examined for license to practice dentistry in the State of West Virginia.
NAME
(LAST) (FIRST) (MIDDLE)
Name
desired on Certificate
Present
Address
(STREET) (CITY) (COUNTY) (STATE) (ZIP)
(All
correspondence will be mailed to the above address, unless the Board is
otherwise notified.)
PERMANENT
ADDRESS
(WHERE
I MAY ALWAYS BE REACHED)
Date of Birth Place of Birth
Social Security
Number - -
I am a citizen of the United States of America by: Birth Naturalization (Give Date)
If not a citizen of the United States state
declaration of intention to become citizen and show progress toward becoming a
citizen of the United States.
Height Weight lbs.
Complexion Race
Sex Color of Hair Color of Eyes
I am (check one) Married Single Divorced
Name of Spouse (if
married)
If Married, maiden
name (if applicable)
Pre-dental Education:
Date of graduation
from and name of high school or preparatory schools.
Colleges attended and
degrees earned (state inclusive dates of attendance)
Dental Education:
Dental Schools
attended and degrees earned (state inclusive dates of attendance)
Graduate work of
internship (Give dates)
List all licenses held
in other states past and present and
dates issued.
Have you had an
application for license refused from any state? If yes explain and give dates
Have you taken and
passed the National Boards?
Dates
Part I Dates Part II
Have you taken and
passed a state or regional clinical board?
If so, which one?
(Dates) (Dates)
I belong to the
following professional societies and organizations:
If I am licensed to
practice dentistry in West Virginia, I plan to (open my own office, intern at
,
enter the armed forces, join Dr. , etc.):
in West Virginia starting
I offer the following
references of good moral character, neither of whom is related to me or is a
teacher at any dental college I attended, who shall write letters, directly to
the secretary of the Board concerning the applicant. (If possible have dentists practicing in the State of West
Virginia.)
Name Name
Address Address
Occupation Occupation
Physician’s Statement of Examination of
Applicant
I,
,
a duly licensed physician of
the State of ,
have this day examined
The applicant herein,
and my medical examination reveals that such applicant is free from all
infectious,
malignant, and
contagious diseases, and such applicant is in sound and good health. Examination made
in , State of
,
on the day of , A. D. 20 .
,
M. D.
For the past ten years, my addresses
and occupations have been: (Please fill
in this section, whether or not you were employed.)
Dates Addresses Occupation
Have you ever been
charged with, or convicted of a crime of the grade of felony? If yes explain:
Have you ever been
charged with, or convicted of, or been a party to a violation of the dental
laws of this or any other jurisdiction? If yes explain:
Father’s Name Mother’s Name
Address Address
Occupation Occupation
Has your surname ever
been changed? If so, when and from what?
In addition to the
foregoing information, I add the following:
1. I will read the Dental Laws of West
Virginia before appearing for examination and I intend to practice Dentistry in
keeping with the spirit and the letter of these laws.
2. I hereby give my permission for the
West Virginia Board of Dental Examiners to secure additional information
concerning me or any of the statements in this application from any person or
any source the Board may desire.
3. I further agree to submit to
questioning by the Board or any member thereof, and to substantiate my
statements when necessary.
4. I shall present my diploma from the
dental school granting my degree at the time set for the examination, if
required or requested by the Board. At
the same time, I shall present all other credentials required or requested by
the Board.
5. I am enclosing a postal money order or
a check in the amount set forth below to cover this examination fee. I understand that this fee is not
refundable.
In State application
fee
- $50.00 The
above statements are true in every particular.
Out of State application fee
- $100.00
Temporary permit
- $100.00
Teaching permit
- $100.00
Intern permit
- $50.00 Signature
THE STATE OF
COUNTY OF Affix
PHOTOGRAPH
Before me,
a Notary Public in and for said State and County, on
No
caps or hats
this day personally appeared please
and did in my
presence sign the foregoing application and acknowledged
to me that all
statements, facts, and answers contained in this application
are true and correct;
and that the applicant executed this application for
the purposes and
consideration therein expressed.
I also certify that the photograph
attached hereto is a likeness of
the applicant.
Witness my hand and seal of office
on this the day of , A. D. 20 .
Signature
of Notary Public
Name
of Notary Public typed
(SEAL) Notary Public in and for the County of
State
of
My
Commission expires
I, ,
Dean of have
read this application of the above applicant for examination before the West
Virginia Board of Dental Examiners, and I certify such applicant to the West
Virginia Board of Dental Examiners as a graduate of this college; and I further
state that the degree of was conferred on such applicant on the day of , A. D. 20 .
Witness my hand as Dean of the above
stated college or university, and the seal of such institution.
Dean
(Seal of College or
University
Conferring Dental
Degree)
Please make all check and money orders payable to “West
Virginia Board of Dental Examiners”.
INFORMATION
CONCERNING LICENSURE TO PRACTICE
DENTISTRY IN THE STATE OF WEST VIRGINIA
REQUIREMENTS FOR PERMANENT LICENSURE:
1. Passage of the National Board examination with scores to be sent directly from the national Board to the West Virginia Board. The address and telephone number of the National Board are as follows: 211 E. Chicago Avenue, Chicago, IL 60611; Area Code 312-440-2678.
2. Passage of the Northeast Regional Board examination or any other state and/or regional board. Results must be verified directly to this office by the agency or state that administered the examination. For information concerning the NERB, write: Lillian Bachman, 8484 Georgia Avenue, Suite 900, Silver Springs, MD 209101 or call NERB at 301-563-3300.
3. Examination concerning the dental laws of the State of West Virginia.
4. Personal interview with the West Virginia Board of Dental Examiners. (The interview will be conducted at the time the law examination is given.)
5. References of good moral character as shown on the application must be written directly to the Board by your reference. If possible, use dentists practicing in the State of West Virginia.
6. Payment of application fee of $50.00 for in State applicants or $100.00 for out of State applicants.
7. Letter of recommendation and good standing from the State Board of any state in which you are or were ever licensed, which must be mailed direct from the State Board to the West Virginia Board.
Please do not leave lines blank all lines must be completed
REQUIREMENTS FOR TEMPORARY PERMITS, TEACHING PERMITS, OR DENTAL INTERN PERMITS:
1. The following application fees are to accompany application:
Temporary permit - $100.00
Teaching permit - $100.00
Intern permit - $50.00
2. Examination concerning the dental laws of the State of West Virginia
3. Personal interview with the West Virginia Board of Dental Examiners. (The interview will be conducted at the time the law examination is given.)
4. Letters of reference of good moral character as set forth hereinabove.
5. Letter of recommendation and good standing from the State Board of any state in which you are or were ever licensed, as set forth hereinabove.
Please note, however, that none of the above permits are available if a person has previously failed a board in another state and the same has not been rectified; if he has had his license suspended or revoked in another state; if applicant has taken the Northeast Regional Board or any other state and/or regional board, he is only eligible for permanent licensure in the State of West Virginia.
TEMPORARY PERMITS:
Temporary permits must have a letter to the West Virginia Board of Dental Examiners from the public health service program under which you are working requesting said temporary permit. Please note that a temporary permit shall only be utilized to work in that public health service program as applied for and no where else. Further, a temporary permit shall expire thirty days after the date of the next Northeast Regional Board or any other state and/or regional board examination given in West Virginia, and shall not be subject to renewal.
TEACHING PERMITS:
A teaching permit is only available for teaching at accredited institutions in the State of West Virginia with a letter of certification from the dean or president of said institution requesting the same, and shall only be utilized for teaching in that particular institution. Further, a teaching permit shall be valid for a period of one year and may be reissued by the Board in its discretion.
DENTAL INTERN OR DENTAL RESIDENCY PERMITS:
A dental intern or dental residency permit is for a person doing work in a specialty or postgraduate field which must have a request from the institution sponsoring said program, which permit shall only be utilized in the educational program. Further, a dental intern or dental residency permit shall expire at the end of one year or on the date the dental internship or residency is discontinued, whichever first occurs.
INFORMATION FOR ALL APPLICANTS:
West Virginia does not require United States citizenship for licensure, but, however, does require a certificate showing the applicant's intention of obtaining citizenship in the United States. Further, West Virginia shall not issue a license and/or any permit unless the applicant is a graduate of a school accredited by the American Dental Association.
In order to be able to sit for any examination or interview, as hereinabove mentioned, the deadline for receipt of the applications by the Board is three (3) weeks prior to the next meeting of the Board.
Please note that if any applicant fails to show for a meeting with the Board after notification, the applicant will not be informed of the next examination and interview unless the applicant specifically writes requesting information of the next Board meeting.
Further, all blanks in the application must be filled in with photograph attached and sealed by a notary public and/or school where applicable or the same shall be returned for completion. If certain sections are not applicable, please denote this by placing N/A in the blank on the application. Please note that the application must show your addresses for the past ten years regardless of whether or not your were employed.
The State of West Virginia DOES NOT have reciprocity with any other state.
A copy of the West Virginia State Dental Law and Dental Regulations can be obtained through this web site, which pursuant to the application shall be read by the applicant prior to the examination as denoted on the application.