Application For Dental Hygienist Licensure - Delaware Board Of Dentistry And Dental Hygiene Page 5
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9EDUCATION – All applicants complete this section.
10. Enter the following information about your high school education:
Name of High School: __________________________________________________________________________
City: ____________________________________________________________ State: ______________________
Dates Attended: From: _______________ To: _________________ Graduation Date: ______________________
month/day/year
month/day/year
month/day/year
Arrange for the Board office to receive your official high school transcript or verification of GED, sent directly
from the school.
11. Enter the following information about your dental hygiene education.
Name of School: _______________________________________________________________________________
City: ____________________________ State: ______________________ Degree: ________________________
Dates Attended: From: _______________ To: _________________ Graduation Date: _______________________
month/day/year
month/day/year
month/day/year
Arrange for the Board office to receive an official transcript, sent directly from your dental hygiene school to
the Board office. If you are applying by examination, the Board office must receive it before the exam
deadline.
LICENSURE HISTORY – All applicants complete this section.
12. Enter the following information about your National Board Examination:
Year Taken:_________________ Score:______________
•
Arrange for the Board office to receive your National Board Examination
score
report, sent directly from
the Joint Commission on National Dental Examinations to the Board office.
•
In addition to passing the Delaware Practical Board Examination, you must also submit your completed,
signed and notarized
Jurisprudence Examination for Dental Hygienist
Candidates.
13. Have you ever been denied a license? Yes
No
If yes, enter: Year Denied: _________ State: ____________
Explain why the license was denied: _______________________________________________________________
_____________________________________________________________________________________________
14. Are you (or have you ever been) licensed in any other jurisdiction? Yes
No
If yes, enter the following
information about each license:
JURISDICTION
LICENSE NUMBER
ISSUE DATE
EXP. DATE
STATUS (e.g.,active)
Arrange for each jurisdiction listed to send a verification of licensure directly to the Board office.
PRACTICE HISTORY – Reciprocity applicants complete this section.
15. Complete the following table to show that you have actively practiced three of the past five years.
DATES
EMPLOYER NAME
CITY
STATE
(month/day/year)
FROM
TO
Enclose Tax form W-2s documenting the periods listed above.
Revised 9/2017
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