Name (last, first, middle) - Minnesota Board of Dentistry

LOCATION OF GUEST LICENSURE PRACTICE11. Name of public health clinic:12. Practice Address (street) City, Zip13. Telephone (include area code)( )Supervisor’s NameYES NO14. I agree to treat indigent patients who meet the eligibility criteria established by the public health cliniclisted in items 11-13. 15. I understand that a guest license to practice dental hygiene in Minnesota allows me to practice only at thespecific location listed in items 11-13. 16. I understand that, should the public health clinic in which I practice cease to operate, my guest licensewill be revoked. It will be my responsibility to notify the Board of all changes in the clinic operation withregard to my license. 17. I understand that it will be my responsibility to notify the Board immediately if my licensein a border state is terminated or disciplined for any reason. 18. I understand that while practicing under a guest license, I have the same obligations as a dental hygienistwho is licensed in Minnesota and I am subject to the laws and rules of Minnesota and the regulatoryauthority of its Board. 19. I have included a letter from the clinic listed in item 10 that: (i) includes a statement, program descriptionor other indication that the clinic provides dental care to patients who have difficulty accessing dental care;and (ii) provides a copy of the IRS letter that indicates that the clinic has been established by a nonprofitorganization that is tax exempt under chapter 501 (c) (3). 20. EMPLOYMENT – Professional (List each dental practice where you currently practice dentistry. Use a separate sheet ifnecessary.)Primary Secondary OtherName of Practice _________________________ ____________________________ __________________________Address_________________________ ____________________________ ___________________________________________________ ____________________________ __________________________Phone No.SupervisorDutiesAverage Hours_________________________ ____________________________ ___________________________________________________ ____________________________ ___________________________________________________ ____________________________ ___________________________________________________ ____________________________ __________________________- 2 - Continued…

PROFESSIONAL BACKGROUND21. Circle each state where you currently practice dental hygiene: North Dakota South Dakota Iowa Wisconsin22. AFFIDAVIT OF LICENSUREThis Affidavit of Licensure, copy thereof, or official letter that includes this information must be completed by the licensingauthority of each state circled in item 21. The original, containing an official signature and seal, must be submitted.I, ____________________________________________ Secretary/Chair of the ______________________________________________________________________________________ hereby certify that ___________________________________________was granted license number ___________________ to practice dental hygiene in state/province of _________________________on the ________ day of __________________, ____________, and that this license is: active terminated ______________.(month) (year) (date)I further certify that disciplinary action: has been taken against said licensee* has not been taken against said licensee; AND is pending* is not pending that pending disciplinary action cannot be confirmed or denied.(SEAL)*Please attach a statement pertaining to disciplinary action, if any.Dated this _______ day of ________________, 20_______.Signed __________________________________________(Signature of Secretary or Chair)Title ____________________________________________YES NO23. Have you ever been suspended from practice, reprimanded, censured or otherwise disciplined ordisqualified as a dental hygienist or other professional? (If so, attach a statement indicatingreason for action, dates, disposition and address of licensing authority in possession of record.) 24. Do you have any criminal charges pending against you? (If so, attach a statement giving full detailsincluding reason, dates, name and location of court, and case number.) 25. Have you ever been convicted of a felony or gross misdemeanor? (If so, attach a statement givingfull details including reason, dates, name and location of court, and case number.) 26. Are there any unsatisfied judgments against you that resulted from the practice of dental hygiene?(If so, attach a statement giving details including nature of judgment, dates and reasons for non-payment.) 27. Based on your assessment or that of another professional, does your use of alcohol or drugs, or theexistence of a physiological or psychological medical condition, in any way impair or limit yourability to practice dental hygiene with reasonable skill and safety?If yes, please 1) explain the use or medical condition, and 2) explain whether the impairment(s)or limitation(s) caused by your use of alcohol or drugs or by the existence of your physiologicalor psychological medical condition are reduced or ameliorated because you receive ongoingtreatment or because of the manner in which you have chosen to practice . (Please provide theseexplanations on a separate attachment to your application.) 28. PHOTOGRAPHFor identification purposes,please tape one passport sizephotograph here, taken withinthe last six months.- 3 - Continued…

YesNo I attest to the fact that I am fully knowledgeable of the laws of Minnesota including the delegation of duties to allied staffand all other Minnesota Statutes and Rules.AFFIDAVIT OF APPLICANT29. STATE OF ____________________ )COUNTY OF __________________ )ss.I, ______________________________, the applicant being first duly sworn, certify that I am the person referred to inthis application for guest dental hygiene licensure, that under penalty of perjury all the information contained in thisapplication and in any attachment or additional document submitted herewith is true and correct and that all persons andorganizations, whether public or private, are authorized to release to the Minnesota Board of Dentistry any information,files or records requested in connection with this application.APPLICANT’S ORIGINAL SIGNATURE _____________________________________________(Sign before a Notary Public)Sworn to before me this _______ day of _______________________, 20 ____My Commission expires ____________________________________________(SEAL)________________________________________________________________Notary Public SignatureNOTES – PLEASE READ CAREFULLY:a. Please be sure all FOUR pages of this application are completely filled out. Incomplete applications WILL bereturned to you without action pursuant to Minnesota Rule 3100.1500.b. Remember to attach the required original documents or NOTARIZED photocopies listed in items 6 and 10. (Anotarized copy is a photocopy that is certified to be a true copy of the original document and is signed andstamped/sealed by a notary public.)c. Remember to attach the required letter from the clinic you will work in (item 19) and an “Affidavit of Licensure” (item22) from each border state where you currently work.d. Your check or money order for $50 should be payable to the Minnesota Board of Dentistry. Pursuant to MinnesotaStatutes Section 332.50, there will be a $20 service charge on all checks not honored by your bank.e. If you fail to notify the Board of changes in operation of the public health clinic in Minnesota that you practice at withregards to your license, or if you fail to notify the Board of the termination or discipline of your licensure in a borderstate, you may be subject to disciplinary action.APPLICANT NOTESQUESTION NUMBERANSWER_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ PLEASE DO NOT WRITE BELOW _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _____ DIP ____ ____ PHOTO ____ ____ LOG____ EXAMS ____ ____ OTHER ____ ____ COMP ENT____ JURIS ____ ____ FEE ____ ____ CERT- 4 -

MINNESOTA BOARD OF DENTISTRYUniversity Park Plaza, 2829 University Avenue SE, Suite 450Minneapolis, MN 55414-3249 www.dentalboard.state.mn.usPhone 612.617.2250 Fax 612.617.2260Toll Free 888.240.4762 (non-metro)MN Relay Service for Hearing Impaired 800.627.3529JURISPRUDENCE EXAMINATION INFORMATION** IMPORTANT **You will need two documents to prepare for the required jurisprudence examination. Onedocument is the Minnesota Dental Practice Act. This book can be purchased through theMinnesota Bookstore at 660 Olive Street, St. Paul, MN 55155, www.minnesotasbookstore.commetro (651) 297-3000 or nationwide (800) 657-3757. This information can also be accessed onthe Board website at www.dentalboard.state.mn.us; from the homepage go to Statutes and Rules,and study all documents listed under Board Statutes and Rules, and the first five documentslisted under Board Related Regulations.We also suggest that you familiarize yourself with the current CDC guidelines. These can befound on their website at www.cdc.govAll applicants for Minnesota licensure or registration are tested on the same subject matter. (Thesame test is used with dental, dental hygiene and dental assisting applicants, so it is importantthat examinees study all of the statutes and rules, not just those that apply only to their particularprofession.)As of April 1, 2002, administration of the exam has been conducted by EVALCOR, undercontract with the Board. EVALCOR schedules test dates at dental, dental hygiene, and dentalassisting schools throughout Minnesota. EVALCOR charges a $40 fee to test takers each timethey are required to take the examination. Please apply to take the exam at least ten days beforeyour preferred test date with the enclosed application; you may contact EVALCOR at651.641.0266 or www.evalcor.us for a schedule of exam times and locations.Below are answers to some frequently asked questions:• You must bring photo identification with you to the examination.• The examination consists of 100 multiple-choice questions.• In the event the examinee does not achieve a passing score of 75%, the individual mayretake the test until a passing score is achieved.• The test may not be taken more than once on the same day.• An application must be submitted to EVALCOR with the $40 fee at least two weeks prior toyour preferred exam date. Applications are accepted by EVALCOR on a first-come firstservedbasis.• Your passing exam is valid for licensure or registration application for up to five years.K:\LICENSING\Applications\Packets\Forms For RDA-before-packet\Jurisprudence info.doc3/19/07

Application to Take theMinnesota Dental Jurisprudence ExaminationPlease Print or type the following information:Namefirst namelast nameDaytime PhoneAddressStreet and numberapt,Evening PhoneCity or Town State Zip CodeSocial Security Number: __ __ __ - __ __ - __ __ __ __I will be applying to be licensed or registered as aDental Assistant Dental Hygienist DentistI received (or am receiving) my dental education atplease list institutionLocation and date of test I am applying for (see back of this page for a schedule):DatelocationYou must submit this application to Evalcor at least two weeks before the test date thatyou have chosen. A ticket of admission will be mailed to you about 10 days before thetesting session you have chosen above. If you wish to change the date of your test, yourrequest must be received by Evalcor in St. Paul at least two weeks in advance of the testselected. Failure to show up at the test session you have chosen without prior approvalfrom Evalcor will result in a forfeiture of the fee paid. A fee of $40 must be enclosed withthis application. (See Evalcor website for Exam schedule.)Please check one of the options below (we do not take credit cards).I am enclosing a check or money order for $40 with this application.Please make your check or money order payable to Evalcor and mail to:K:\LICENSING\Jurisprudence\Application to take jurisprudence.docEvalcor1567 Summit AvenueSaint Paul, MN 55105-2244Tel: 651-641-0266 Fax: 651-646-7609www.evalcor.us