Provide the necessary personal information
in the fields to the right. All fields with (*) are required and must be
completed to continue the application process. Demographic and workforce data
collected for some licensed healthcare professions is used to enhance the
state’s capacity for healthcare workforce forecasting, policy development, and
research. This data is used to analyze the supply and demand of the healthcare
workforce serving Ohio. If you do not have an Individual Provider Identifier
(NPI) number please enter nine zeroes.
Title
First Name
Middle Name
Last Name
Maiden Name
Social Security Number
Date of Birth
Email Address
Phone Number
Cell Phone/Mobile Number
Other Phone Number
What is your U.S. Residency
status related to your employment?
Do you consider yourself
Hispanic, Latino/a or of Spanish origin?
What do you consider your race?
List languages you personally use to
communicate with patients excluding an interpreter or software
Other Language
Individual National Provider
Identifier - if N/A enter all zeroes
Enter home US zip-code. Enter NA if unavailable
Provide the necessary additional
information in the fields to the right. All fields with (*) are required and
must be completed to continue the application process. Â If you were
born in the United States, you will need to list the city and state where you
were born.
Do you have other aliases?
Please list all other aliases.
What is your gender?
In which country were you born?
In which state were you born (if United States)?
In which city were you born?
Demographic and workforce data
collected for some licensed healthcare professions is used to enhance the
state’s capacity for healthcare workforce forecasting, policy development, and
research. This data is used to analyze the supply and demand of the healthcare
workforce serving Ohio.
What is your primary employment status?
Which of the following best describes
your five-year employment plan?
Are you currently employed outside of USA?
Please choose a public license
mailing address from the dropdown options (this is the address that will be
viewable by the public). To add a new address, click on ADD ADDRESS, fill out
the necessary fields, and then click Save. To remove an address, click on
DELETE ADDRESS and select the delete icon next to the
address you wish to remove.
Please choose a mailing address
from the dropdown options (this is the address used for all postal
communications from the Board for this license). To add a new address, click on
ADD ADDRESS, fill out
the necessary fields, and then
click Save. To remove an address, click on DELETE ADDRESS and select the delete icon next to the address you wish to remove.
Residency Applicants: If you are applying for a Dentist License through the
Residency Application type, please include your school address as your mailing
address, so that the proper documentation can be sent there.
If you have served in the military, provide the information for the type of service and duration of the service. Also, provide proof of your service. If you answer YES to either of the first two questions, you will be required to complete the additional questions listed.
Have you served in the military?
If you answered "Yes",
are you currently serving in the military?
Has your spouse served in the military?
If you answered "Yes",
are they currently serving in the military?
I declined to answer these questions
To add an educational institution
to your profile, click the ADD EDUCATION button. Begin typing the name of the
school into the Education Institution field. As you type, the name of your
school should auto-populate. Once it does, click on it to select it. If your
school does not auto-populate, please type the word “Other”, then select it, to
add a school that is not listed. You will then enter you
school’s name and
address in the fields that
appear. Repeat this process for all education entries. All fields marked with
(*) are required. Once finished, continue with the next Background sections or
click the SAVE ADD CONTIUE button. If you did not receive a degree, please
select "Not Applicable" as the degree type and do not enter a
graduation date.
To add an entry to your
employment history, click the Add Work History button. Complete the information
fields and click Save. Repeat this process for all employment entries. All
fields marked with (*) are required.
List all states and/or
jurisdictions in which you have ever held a health-related license. To add a license you currently hold or previously held, click the Add
License button. Complete the information fields and click Save. All fields
marked with (*) are required. Repeat this process for each additional license
you hold or held. To edit an added license, click the
pencil icon.
Please
provide the following information for all practice sites where you use this
license, beginning with the locations in which you spend most of your time. If
you are not actively working or volunteering in a position that requires this
license (e.g. student or recent graduate) employment location information is
optional.
Employment location information
helps improve the accuracy and efficiency of Health Professional Shortage Area
Designations and enables Ohio to identify healthcare workforce distribution.
After your Employment Location data has been entered
please click the SAVE EMPLOYMENT LOCATION button before Saving and Continuing.
Answer the following questions
Yes, No, or N/A if it doesn't apply to you. Any answer
that requires an explanation will be on the Uploads
section of this application. Once completed, click "Save and
Continue" to progress through the application.
Question - Are you currently
licensed or have you ever held a health-related license in another state or
jurisdiction?
Question - Have you been
convicted of, found guilty pursuant to a judicial finding of, or plead guilty
to any felony or misdemeanor? (Exclude all traffic violations, except those
involving driving while under the influence of alcohol or drugs). If YES, it is
REQUIRED that you provide (1) court documentation showing what the charges
were, and (2) a detailed personal statement giving an
explanation of those charges.
Answering yes does not
automatically bar you from licensure. Applications will be reviewed on a case by case basis.
Question - Do you have any
criminal charges pending against you? If YES, attach a statement giving details
of the matter and the name and address of the authority in possession of the
record thereof.
Question
- Are you currently suffering from any condition for which you are not being
appropriately treated that impairs your judgement or that would otherwise
adversely affect your ability to practice in a competent, ethical, and
professional manner? If yes, attach statement, giving
a full explanation.
Question - Are you engaged in the
current illegal use of controlled substances, or other habit-forming drugs, or
alcohol, or other chemical substances? If YES, attach a statement giving full
explanation, dates, places, etc.
Question - Have you been
permitted to practice in each of the states/jurisdictions you listed on your
application continuously since first issued until present? If you answer, “No”,
you will be required to provide
an explanation.
Question - Have you been
suspended from practice, reprimanded, censured, or otherwise disciplined or
disqualified as a dentist or a member of any profession? If yes, please state
the dates, the facts, the disposition of the matter and the names and address
of the authority in possession of the record thereof. (Attach Statements).
Question - Have you ever been
refused dental licensure by any jurisdiction(s)? If not
applicable please indicate N/A. If Yes,
please indicate where and why.
Question - Please select the Regional exam that you took. Note you must have passed all
parts of the exam and will be required to submit a copy of your exam scores.
If applicable, upload the
Attachments for your license application by clicking the Add Attachment
button(s). If uploading an attachment as a submission, it is necessary that the
name of the file attachment is less than 80 characters in length for it to be
received successfully. The character limit does include the file attachment
extension, such as (.doc) and (.pdf).
The (.exe) and (.html) file extensions are not supported for submissions. For
documentation that needs to be submitted directly to the Board or by hardcopy,
please acknowledge by clicking the Attest button(s). If no attachment or
attestation items appear, please click the Save and Continue button.
Notarized
Credentials in English Translation: Diploma
Description - Upload copy of diploma
or evidence of graduation from a dental school. Credentials must be in English
translation and notarized
Notarized
Credentials in English Translation: Transcripts
Description - Must upload
complete transcripts of all academic grades in dental school with courses
completed, along with pre-dental school transcripts. Credentials must be in
English translation and notarized.
Proof of 5+ years of licensure OR
Regional exam scores Description - Proof of 5+ years of licensure OR Regional
exam scores
Hepatitis B Immunity or Immunizations – Proof of
one of the following:
Description
- 1. Immunity – Positive/Reactive/>10 Hepatitis B Antibodies Titer 2.
Immunizations – Three traditional shot dates, or Two Heplisav-B shot dates
(vaccine type/name must be clearly indicated on shot record)
Jurisprudence
Exam
Description - This exam is
required for licensure and can be found at www.dental.ohio.gov. Please
upload your signed exam answer sheet. If any follow up is required on your
exam, the Dental Board will contact you.
Completed
Minimum 2 Years Clinical Training – Upload BOTH of the following:
Description - Proof of
completing a two year accredited GPR or AEGD. School seals must be visible and
legible: 1. Completed Certificate of Clinical Training Form found at www.dental.ohio.gov.
AND 2.
Certificate
of Completion.
National
Board Dental Examination – Upload
Description
- Proof of passing the National Board Dental Examination (NBDE) (scores).
Passing
Score from TOEFL or English Language Service Test
Description - You must upload a
passing score from ONE of the following: 1. Test of English as a Foreign
Language (TOEFL) OR 2. English Language Service Test
Criminal
Records Check
Description - I acknowledge
that I will complete the BCI and FBI criminal records check. Instructions to
complete this process can be found at www.dental.ohio.gov.
Basic
Science and Laboratory Exam
Description - Proof of completing
the Basic Science and Laboratory Exam Requirement – Upload Completed
Attestation Form.
Once the
review has been processed, the license application will be completed.
Application Review -
I understand that submitting a
false, fraudulent, or forged statement or document or omitting a material fact
in obtaining licensure may be grounds for disciplinary action against my
license, certificate or registration. Under
penalty of law, I hereby swear or affirm that the information I have provided
in the application is complete and correct, and that I have complied with all
criteria for applying. By subscribing to this electronic attestation, I certify that that the statements contained in this
electronic application are true in every respect.
Consent
to Electronic Signature -
Date/Time
Stamp –
Type your First Name and Last
Name as they appear on the application to sign electronically.
Submit your Application -After
clicking the ‘Submit’ button below, you will no longer be able to change this
application.
PLEASE DO NOT USE THE
BROWSER'S BACK BUTTON AS THAT MAY OVERWRITE YOUR DATA.
If you want to return to your
application, simply log out and log back in.
If this application requires payment you will be prompted to begin the payment process.
You must complete the payment process before the board will
review your application. If this application does not require payment,
you will be navigated back to the eLicense home page
and the board will review your application.