Dentist Faculty Member License Instructions (Page 2 of 2) in pdf

EXAS

TATE

OARD OF

ENTAL

XAMINERS

333 Guadalupe Tower 3, Suite 800

DENTIST FACULTY MEMBER

Austin, Texas 78701-3942

Phone: (512) 463-6400 | Fax: (512) 463-7452

LICENSE APPLICATION

E-Mail: licensinghelp@tsbde.texas.gov

Website:

Instructions:

FEE: $186

 Answer all questions.

 Incomplete applications will be returned without action.

Military Active Duty, Veterans and

 Mail with this application all required documents as listed on Page 1 of the instructions.

Military Active Duty Spouses: No Fee

________________________________________

_________________________________

_______________________________________

First Name

Middle Name

Last Name

_______________________________

_______________________________________

________________________________

Date of Birth

Social Security Number*

Applicant E-Mail Address

________________________________________

___________________________

___________

(______) ___________

Mailing Address

City

State

Zip Code

Telephone

Military

Not

Active

Military

Military Active Duty

Status:

______ Military

______ Duty Military**

______ Veteran**

______ Spouse**

________________________________________

___________________________

_____________________________________________

Employing School

City

Assigned Department

* - The TSBDE requires an applicant to provide a SSN as a part of the licensure, certification or registration process. The SSN of an applicant for a license, certificate,

or registration or other legal authorization issued by the TSBDE is confidential and not subject to disclosure under Chapter 552 of the Texas Government Code.

** - If you are military, include a copy of one of the following: Copy of Military Orders, I.D. Card or proof of Honorable or General Discharge.

EDUCATION:

_____________________________________

______________________________________

_____________________

Name of School

Degree Awarded

Year Graduated

_____________________________________

______________________________________

_____________________

Name of School

Degree Awarded

Year Graduated

HEALTH INSURANCE QUESTIONS:

Are you a Texas Medicaid Provider? ______Yes ______No

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

TO BE COMPLETED BY DEAN, DEPARTMENT CHAIR, OR PROGRAM DIRECTOR:

I, _________________________________________________, verify that the above-named applicant holds a ____ Part Time ____ Full Time ____

Salaried position with the following teaching institution:_________________________________ and is a fit and proper candidate to be issued a faculty

license to provide direct patient care within this institution or its adjunct facilities.

_______________________________________

___________________

Signature of Dean, Department Chair, or Program Director

Date

IN ADDITION TO THE FOREGOING:

A. I hereby give my permission for the Texas State Board of Dental Examiners (TSBDE) to secure additional information or documentation concerning me or

any of the statements in this application from any person or source the TSBDE may desire.

B. I further agree to submit to questioning concerning my qualifications as an applicant by the TSBDE, staff, any member or agent thereof, and to substantiate

my statements if desired by the TSBDE. I also agree to present all other credentials required or requested by the TSBDE.

C. I, the applicant herein, state that all facts, statements and answers contained in this application are true and correct. I am not omitting any information,

which might be of value to this Board in determining my qualifications whether it is called for or not. I agree that any falsification, omission, or withholding or

pertinent information or facts concerning my qualifications as an applicant shall be sufficient to bar me from licensure by the TSBDE and such falsification,

omission or withholding shall serve as sufficient grounds for the revocation, cancellation, or suspension of my Texas license if it is not discovered until after

issuance.

__________________________________________

_________________________

Signature of Applicant

Date

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.

_____________________________________________