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.
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
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.
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?
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.
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.
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.
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.
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.
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.
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)
Dental radiographer education - Proof of one of
the following:
Description - 1. Current
certification as a dental assistant through DANB, CODA or AMT w/ expiration
date; or 2. Copy of Board-approved dental x-ray educational course certificate
of completion.
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.