Application For Dental Hygienist Licensure - Delaware Board Of Dentistry And Dental Hygiene Page 9
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9: (302) 744-4500
TELEPHONE
C
B
ANNON
UILDING
: (302) 739-2711
FAX
STATE OF DELAWARE
861 S
L
B
., S
203
ILVER
AKE
LVD
UITE
:
.
.
WEBSITE
DPR
DELAWARE
GOV
D
, D
19904-2467
OVER
ELAWARE
EMAIL
customerservice.dpr@state.de.us
:
AUTHORIZATION FOR RELEASE OF INFORMATION
CRIMINAL HISTORY RECORD CHECK FOR PROFESSIONAL LICENSURE APPLICANTS
Please print or type all information in black ink.
Check the type of license for which you are applying:
Adult Entertainment
Mental Health
Physical Therapy/Athletic Trainer
(LPCMH, LCDP, LMFT, LAPCMH, LAMFT)
Charitable Gaming Vendor
Nursing (RN, LPN, APRN)
Podiatry
Chiropractic
Nursing Home Administrator
Psychology
Real Estate Appraiser
(includes
Dental
Occupational Therapy
Appraisal Management Company)
Funeral
Optometry
Speech/Hearing
Pharmacy
(includes key personnel of facilities licensed by
Massage
Social Work
Board of Pharmacy)
Medical
(Physicians, Physician Assistants, Respiratory Care Practitioners, Eastern Medicine Practitioners,
Texas Hold’em Individual
Acupuncture Practitioners, Genetic Counselors, Polysomnographers, Midwifery Practitioners (CM, CPM))
Print your current full name:
____________________________________ ____________________________________
________________ _______________
Last Name
First Name
Middle Initial
Suffix (e.g., Jr., Sr.)
Enter all other names you have used in the past (including, but not limited to, maiden name, former married
names, alternative spellings):
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
As an applicant, I authorize release of any and all information that you have concerning my CRIMINAL HISTORY
RECORD INFORMATION. I hereby release you, your organization, the State of Delaware and others from any liability or
damage which may result from furnishing this information:
SIGNATURE OF PERSON PRINTED: __________________________________________ Date: _________________
Phone:
Home _______________________ Work _______________________
Mail the results of my criminal history request to:
Division of Professional Regulation
861 Silver Lake Boulevard, Suite 203
Dover DE 19904
SLC D420A
USE OF CRIMINAL HISTORY RECORD INFORMATION IS RESTRICTED BY LAW AND SHALL BE LIMITED TO THE
PURPOSE FOR WHICH IT WAS GIVEN. MISUSE CONSTITUTES A CRIMINAL VIOLATION.
Revised 9/2017
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