Texas State Board of Dental Examiners
333 Guadalupe, Tower 3, Suite 800
Austin, Texas 78701-3942
Phone: (512) 463-6400
DENTAL ASSISTANT RENEWAL FORM
INSTRUCTIONS: A RDA Registration Certificate may only be renewed within 45 days of its expiration date. Make your check or money order payable to the SBDE.
EXPIRATION DATE: ________________________
1. BASIC LIFE SUPPORT CPR COMPLIANCE:
Check One. All dental assistants in Texas must hold a current Basic Life Support CPR Card.
______ My BLS CPR is current. CPR Card Issued Date: _____________________
CPR Card Expiration Date: _____________________
______ My BLS CPR Card is not current. I am attaching my physician’s letter of explanation or proof of residence outside the U.S.
2. ANNUAL REGISTRATION RENEWAL CONTINUING EDUCATION COMPLIANCE:
______ I am in compliance with completing all required continuing education for this registration period.
______ I am in my first registration period and exempt from completing continuing education for this registration period.
3. DISCIPLINARY ACTION HISTORY:
______ I have not been the subject of disciplinary action not yet reported to the Board.
______ I have been the subject of disciplinary action not yet reported to the Board and I am attaching a letter of explanation and a certified copy of all actions
taken against my license.
4. CRIMINAL HISTORY:
______ I have not been arrested, indicted, convicted or received a court order for any criminal offense not been reported to the Board.
______ I have been arrested, indicted, convicted or received a court order for a criminal offense not yet reported to the Board and I am attaching a letter of explanation
and certified copies of legal documentation pertaining to the arrest, indictment, conviction or court order.
5. HAVE YOU CHANGED YOUR ADDRESS IN THE LAST 60 DAYS:
Important Notice: Your primary mailing address will be displayed online to the public.
______ I have not changed my address in the last 60 days.
______ I have changed my address in the last 60 days. If you have not reported this change to the Board, fill out the section below.
______ Use my Home Address as my primary mailing address
______ Use my Office Address as my primary mailing address.
HOME ADDRESS INFORMATION
OFFICE ADDRESS INFORMATION
State: __________________________ Zip Code: __________________
State: _______________________________ Zip Code: _________________
Telephone Number: _________________________________________
Telephone Number: _____________________________________________
6. HAVE YOU CHANGED YOUR NAME IN THE LAST 60 DAYS:
_____ NO _____ YES
If you answered “Yes” you must include with this renewal form legal documentation showing proof of the name change (e.g., Marriage License, Divorce Decree, etc.) Do
not mail in your annual registration certificate.
PRINT YOUR FULL LEGAL NAME HERE
7. FEES DUE.
Pay all fees as they apply to you. PENALTY FEE NOTE: If paying the penalty fee for being 91-365 days past your expiration date you must also pay the
penalty fee for being 1 to 90 days past due.
Annual Renewal Fee
Penalty Fee if paid 1-90 days after the Expiration Date.
Penalty Fee if paid 91-365 days after the Expiration Date.
Name Change if being made at time of license renewal.
Name Change Fee
TOTAL AMOUNT PAID:
8. SIGNATURE AND DATE.
I hereby attest by my signature, under penalty of perjury, that I have completed and possess all required certifications as required by the Occupations Code and the
TSBDE Rules and Regulations. All information provided on this form is true and accurate and I understand that I may be asked to produce for the TSBDE any
documentation I am required to maintain for licensure.
Dentist Assistant Renewal Form (Applications dated prior to January 2016 are obsolete)
January 1, 2016