Dental Laboratory Renewal Form

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Texas State Board of Dental Examiners
333 Guadalupe, Tower 3, Suite 800
Austin, Texas 78701-3942
Phone: (512) 463-6400
Fax: (512) 463-7452
DENTAL LABORATORY RENEWAL FORM
Website:
Renew Online: You may renew online 45 days before the expiration date listed on your registration certificate and anytime after your registration
certificate expires at the following website address:
Renew by Mail: Make your Check or Money Order payable to the State Board of Dental Examiners and mail it to the address listed above.
INCOMPLETE FORMS WILL BE RETURNED
This form must be signed and all questions answered or your payment will be returned without action resulting in non-renewal and possible penalties.
Renew by
1 - 90 Days
91 days – 365 Days
Profession
Expiration
Following Expiration
Following Expiration
366+ days late
Dental Laboratory
$135
$200.50
$266.00
Canceled - Nonrenewable
Renewing an Expired Registration: See Page 2 for instructions for renewing an expired registration certificate.
Required Jurisprudence Assessment for Dental Laboratories: Dental Labs are required to take the online SBDE Jurisprudence Assessment once every
three years for registration renewal. Go to: More information is available on Page 2.
LAB INFORMATION
Lab Name
Lab Registration
______________________________________________
_________________________
and Address:
Number:
Include full name of
______________________________________________
Lab Phone
City, State, Country
( _______ ) _____________________
Number:
and Zip Code
______________________________________________
LAB OWNER
Name and Address:
Owner Phone
___________________________________________________
Number:
Include full name of
( _______ ) _______________________________
City, State, Country
___________________________________________________
and Zip Code
___________________________________________________
CDT OF RECORD
CDT Certification Number
Issued by the National
CDT OF RECORD IS: __________________________________________________
Board of Certification:
If CDT of Record has changed since last renewal, list the new CDT of Record here:
Expiration Date of
CDT Certification:
DISCIPLINARY ACTION OR CRIMINAL OFFENSES
(
Check the answer that applies to you for BOTH Questions 1a and 1b)
1a. ____ I have not been the subject of any disciplinary action not yet reported to the SBDE
____ I am attaching documents regarding disciplinary action not previously reported to the SBDE.
(or)
1b. ____ I have not been arrested, indicted, convicted or received a court order for any criminal offense not reported to the SBDE
____ I am attaching documents regarding criminal offenses that have not yet been reported to the SBDE.
(or)
GRANDFATHERED LABS
(See Requirements on Page 2)
Indicate the name of the designated employee that has obtained the required
Continuing Education hours required for renewal of this registration:
ADDRESS CHANGE
Complete a change of address NOT reported to the Board here.
Address: ___________________________________________________
City: _____________________________
State: ________________
Country: _________________________________
Zip Code: ___________________
Phone: ( ______ ) __________________________
E-Mail Address:
(Optional) ________________________________________________________________________________________________________
GENERAL REQUIREMENTS
(If this information has not changed since the last registration renewal, you are not required to complete this question below)
All Laboratory renewals must include the following information. List every person having an ownership interest of 20% or greater in the lab. Attach separate sheet if needed.
% and Type of
Date Ownership
Name
Address (City, State, Country, Zip Code)
Ownership Interest
Obtained
________________________________________
________________________________________________________ _________________
_______________
________________________________________
________________________________________________________ _________________
_______________
Manager Name: ______________________________________ Mailing Address: _____________________________________________________________________
AMOUNT DUE
SIGNATURE AND DATE
By signature, I hereby attest that this laboratory is in complete compliance with the
Dental Practice Act and Rules and Regulations of State Board of Dental Examiners regarding the operation of a Dental
Laboratory in Texas. I understand I may be asked to provide copies of any required certification or continuing education
Renewal Fee: $ ____________
documentation required to renew this registration.
Total Payment Enclosed:
$ ____________
Signature
Date
SEE PAGE 2 FOR MORE INFORMATION
08/01/2013

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