Application For Dental Hygienist Licensure - Delaware Board Of Dentistry And Dental Hygiene Page 4
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9: (302) 744-4500
TELEPHONE
C
B
STATE OF DELAWARE
ANNON
UILDING
: (302) 739-2711
FAX
861 S
L
B
., S
203
ILVER
AKE
LVD
UITE
:
WEBSITE
DPR.DELAWARE.GOV
BOARD OF DENTISTRY AND DENTAL HYGIENE
D
, D
19904-2467
OVER
ELAWARE
EMAIL
:
customerservice.dpr@state.de.us
APPLICATION FOR DENTAL HYGIENIST LICENSURE
TYPE OF APPLICATION
1. Select the type of application you are submitting:
Reciprocity – I hold a current license in another jurisdiction and I have practiced as a Dental Hygienist for three of
the past five years. Skip to the
section.
IDENTIFYING AND CONTACT INFORMATION
Examination – I am applying to sit for the Dental Hygienist Practical Board Examination, and I do not meet the
requirements to apply by reciprocity.
2. Check the month when you wish to sit for the Practical Board Examination:
January – I understand that I must submit this application, the processing and examination fees, and copy of my
CPR card and that the Board office must receive my high school verification and college transcript no later than
the deadline of December 1.
May – I understand that I must submit this application, the processing and examination fees, and copy of my CPR
card and that the Board office must receive my high school verification and college transcript no later than the
deadline of April 1.
The examination fee you submit with this application is non-refundable and non-transferable. If you do not sit
for the exams in the chosen month, you will forfeit the fee.
IDENTIFYING AND CONTACT INFORMATION
3. Name: _______________________________ ___________________ ___________________ ________________
Last/Family Name
First
Middle
Maiden
4. Other Name(s) Used: _____________________ _________________________ _____________________ None
5. Have you ever sought or been granted a dental license under another name? Yes
No
If yes, enter name and
state where you used the name: _______________________________________________
6. Date of Birth (month/day/year): ______________ Gender: Male
Female
7. Have you been issued a U.S. Social Security Number? Yes
No
If yes, enter your SSN:_________________
If no, you must file a
Request for Exemption from Social Security Number
Requirement.
8. Mailing Address:________________________________________________________________________________
__________________________________________________ ________________________________ ____________________
City
State
Zip
9. Phone: ___________________ ___________________
Email: _________________________________________
Daytime
Home
Revised 9/2017
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