Dental Licensure By Examination - Texas State Board Of Dental Examiners printable pdf download

Texas State Board of Dental Examiners

333 Guadalupe, Tower 3, Suite 800

Austin, Texas 78701-3942

Phone: (512) 463-6400 / Fax: (512) 463-7452

Website:

Dental Licensure by Examination

E-Mail: info@tsbde.texas.gov

Instructions:

FEES

 Print or type all information. All incomplete applications will be returned without action.

$287

ICENSURE BY

XAMINATION



 Fees are Non-Refundable. The TSBDE accepts Personal Checks, Cashier’s Check or Money

Orders. Do not send cash. Make your payment to the Texas State Board of Dental Examiners.

$287

OREIGN

RADUATE

ICENSURE



 If you move after submitting your application, notify the Board immediately of your new address

, V

ILITARY

CTIVE

UTY

ETERAN



and/or phone number.

& S

 Fingerprint Criminal Record Check results are valid for 6 months from the date they were taken.

POUSE

ENTAL

ICENSURE

 Jurisprudence Assessment Certificate must be dated within the 12 months preceding application.

: $434



EINSTATE A

ANCELED

ICENSE

 Clinical exam results must be dated within the 5 years of when the examination was successfully

passed. All applicants must successfully pass the following exam components: Operative, Endo,

$822

EMPORARY

ICENSURE



Perio, and Comprehensive Treatment Planning.

APPLICATION

_____ Licensure by Examination

_____ Foreign Graduate Licensure by Exam

_____ Reinstating a Canceled Dental License

_____ Military Active Duty, Veteran or Military Active Duty Spouse

_____ Temporary Licensure

PERSONAL INFORMATION

List your Full Legal Name.

First

Middle

Last



Name: ________________________________ Name: ____________________________ Name _______________________________

Active Duty

Social Security

Military



Not

Active

Military

Number*: __________________________________

Status:

______

Military

______

Duty**

______

Veteran**

______

Spouse

List All

Date of



Former Names: _____________________________________________

Birth: ________________________________________

MM / DD / YYYY

* - The TSBDE requires an applicant to provide a SSN as a part of the licensure, certification or registration process. The SSN of an applicant for a license, certificate, or

registration or other legal authorization issued by the TSBDE is confidential and not subject to disclosure under Chapter 552 of the Texas Government Code.

** -

If you are military, veteran or spouse include a copy of one of the following: Copy of Military Orders, I.D. Card or proof of Honorable or General Discharge.

ADDRESS INFORMATION

Your primary mailing address will be displayed on the Board’s website for public use.

Which address will be your Primary Mailing Address?

_______ Home ________ Work



Home Address: ______________________________________________________________



City: _______________________________ State: ____________

Zip: _____________ Country: ________________________

Work Address: ______________________________________________________________



City: _______________________________ State: ____________

Zip: _____________ Country: ________________________

PHONE NUMBER AND E-MAIL

Daytime

Alternate



Phone: ______________________________________________

Phone:

____________________________________________



E-Mail Address: _______________________________________

DENTAL EDUCATION



School



Degree



Graduation

Attended: _____________________________________________

Earned: ________________

Date:

__________________

STATE LICENSURE/JURISDICTIONS

List all states and/or jurisdictions in which you are or have been licensed.

License

Disciplinary

____ Yes

State: _______________________________ Number: ____________________ Issue Date : __________________ Action?

____ No

License

Disciplinary

____ Yes

State: _______________________________ Number: ____________________ Issue Date : __________________ Action?

____ No

Dental Licensure by Examination

February 1, 2016

Dental Licensure By Examination - Texas State Board Of Dental Examiners

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