Dental Licensure By Examination - Texas State Board Of Dental Examiners (Page 2 of 2) in pdf

Application for Dental Licensure

Page 2

HEALTH INSURANCE INFORMATION

Are you a Texas Medicaid Provider?

_____Yes

_____No

Are you a participating provider in the Texas Children’s Health Insurance Program (CHIP)? _____Yes _____No

TEXAS NON-PROFIT CORPORATION EMPLOYER

(For Temporary Licensure Applicants Only)

Corporation

Supervisor

Name:

____________________________________________________

Name:

_____________________________________________

Supervisor

Address:

____________________________________________________

Phone Number: ( _______ ) _______________________________

Employer Medicaid

___________________________ ________ ________

Provider Identification Number: _____________________________

City

State

Zip Code

BACKGROUND INFORMATION

A “Yes” answer to any question listed below requires additional information. Submit a dated and signed letter of explanation and all appropriate

legal disposition papers.

____ Yes

_____ No

Have you ever held a license issued by the Texas State Board of Dental Examiners (TSBDE)?

If yes, include the type of license and license number:

License Type: ___________________________________

License Number: ___________________________

____ Yes

_____ No

For any criminal offense, including those pending appeal have you:

Been convicted of a misdemeanor;

Been convicted of a felony;

Received deferred adjudication;

Been placed on court-ordered probation;

Been sentenced to serve jail or prison time or court-ordered confinement;

Been arrested or have any pending criminal charges;

Been subject to a court martial; Article 15 violation; or received any form of military judgment/punishment/action.

(You may exclude only Class C misdemeanor traffic violations)

Note on Expunged and Sealed Offenses: While expunged or sealed offenses, arrests, tickets, or citations need

not be disclosed, it is your responsibility to ensure the offense, arrest, ticket, or citation has, in fact, been expunged

or sealed. It is recommended that you submit a copy of the Court Order expunging or sealing the record in question

to our office with your application. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged

or sealed, could at a minimum, subject your license to a disciplinary fine. Non-disclosure of relevant offenses raises

questions related to truthfulness and character.

____ Yes

_____ No

Are you currently the target or subject of a grand jury or governmental investigation?

____ Yes

_____ No

Has any licensing authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of,

suspended, placed on probation, refused to renew a license, registration, or certificate held by you now or previously, or

ever fined, censured, reprimanded or otherwise disciplined you?

____ Yes

_____ No

Within the past five (5) years have you been addicted to and/or treated for the use of alcohol or any other drug?

ATTESTATION

In addition to the foregoing: I acknowledge this is a legal document and I attest that I understand and meet all the requirements to practice for the type

of licensure requested. Further, I understand that it is a violation of the Texas Administrative Code and the Penal Code to submit a false statement to a

government agency and I consent to the release of confidential information to the Texas State Board of Dental Examiners and further authorize the

Board to use and to release said information as needed for the evaluation and disposition of my application for licensure.

Applicant’s Signature

STATE OF

COUNTY OF

Before me, the undersigned authority, on this day personally appeared the applicant whose signature appears above and who being by me

sworn upon oath says that all the facts, statements and answers contained in this application are true and correct.

Sworn and subscribed to before me, the said _______________________________________________________ appeared on this

the ___________ day of ___________________, 20 _______, to certify which witness my hand and seal of office.

_________________________________________

Notary Public Signature

(Seal)

Dental Licensure by Examination

February 1, 2016

Dental Licensure By Examination - Texas State Board Of Dental Examiners Page 2

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