Volunteer License Application Form - Oregon Board Of Dentistry
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4OREGON BOARD OF DENTISTRY
1500 SW 1st AVENUE, SUITE 770
PORTLAND, OR 97201
971-673-3200
VOLUNTEER LICENSE APPLICATION
Dental
Dental Hygiene
Name: ____________________________________ License Number: _______ Telephone No.___________
(print legibly)
Mailing Address: _________________________________________________________________________
Street or P.O. Box
__________________________________________________________________________
City
State
Zip Code
Home Address: __________________________________________________________________________
Street
__________________________________________________________________________
City
State
Zip Code
Volunteer Location:
_______________________________________ Telephone No. _________________
Name of Organization
_____________________________________________________________________
Street or P.O. Box
_____________________________________________________________________
City
State
Zip Code
If volunteering at additional location(s), please list the name(s) of the organization(s) and their address(es) on a
separate piece of paper.
I certify that:
1. I am an active licensed Oregon dentist or dental hygienist who will be practicing for a supervised volunteer
clinic, as defined in ORS 679.020(3)(f) and (g). (See Statute on back of application)
2. I am registered with the Oregon Board of Dentistry as a health care professional and that I will meet all the
requirements set forth in ORS 676.345 (Attached).
3. I will not practice dentistry or dental hygiene for remuneration in any capacity under the volunteer license.
4. I will volunteer for a minimum of 40 hours per calendar year.
5. I will comply with all continuing education requirements for active licensed dentists/ dental hygienists.
I understand that:
1. I must surrender my active dental/dental hygiene license.
2. I may surrender the volunteer license designation at anytime and return to an active license once all
active licensure requirements are met.
_______________________________________________________________
_________________
Signature
Date
Rev. 12/2013
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