TEXAS STATE BOARD OF DENTAL EXAMINERS

TEXAS STATE BOARD OF DENTAL EXAMINERSTexas Dental HygieneWestern Regional Examining BoardExaminer Appointment Application1. How to Apply for an appointment as an Examiner associated with the State Board of DentalExaminers (SBDE), Dental Hygiene Advisory Committee (DHAC):The SBDE and the DHAC seek the most qualified Registered Dental Hygienist nominees to recommendto the SBDE as a Western Regional Examining Board (WREB) Examiner from Texas. Please follow theinstructions on the Appointment Application. After completing the application, forward it to:Texas State Board of Dental ExaminersAttention: Office of the Executive Director333 Guadalupe, Tower 3, Suite 800Austin, Texas 78701-3942A current Appointment Application is required for consideration of any candidate seeking nomination bythe DHAC. Applications are due to the TSBDE no later than February 1 st of each year to be consideredfor the next WREB Testing Cycle. The certification portion of the application must be signed before anycandidate can be considered for an appointment. A qualified Registered Dental Hygienist may reapplyannually for consideration.Please note: Any information within the file is subject to the Public Information Act. This means thatanyone requesting copies of the information in your file or requesting to review your file will be providedaccess to the information.2. The Process after Submission of Application:Your name will be considered as a prospective nominee. Any additional information received from you,or from others relative to your appointment, will be kept in your file. If we need additional information,we will contact you.The DHAC will review applications annually for recommendation to the SBDE. The background andqualifications of all applicants will be reviewed.3. Board Confirmation:Applicants will be recommended by the DHAC to the Texas State Board of Dental Examiners (the Board)for formal appointment. The Board will notify applicants of their selection.4. Qualified Appointees:The following criteria must be met:1. Is 18 years of age or older.2. Be a United States Citizen.3. Be a Texas Resident at least three (3) years preceding date of application.4. Has not been adjudged mentally incompetent by a court.5. Has not been convicted of a felony (fulfillment of sentence and pardon exceptions available).5. Maintain a current Texas Dental Hygiene license in good standing.6. Be active in the practice of Dental Hygiene for at least five (5) years.

TEXAS STATE BOARD OF DENTAL EXAMINERSTEXAS DENTAL HYGIENEWESTERN REGIONAL EXAMINING BOARDEXAMINER APPOINTMENT APPLICATIONPRINT IN BLACK INK OR TYPE. Fill out application form completely. If questions are not applicable, enter “NA”. Do not leave questionsblank. Be sure to sign when completed. In consideration of this application, the Texas State Board of Dental Examiners or the Dental HygieneAdvisory Committee does not discriminate on the basis of race, color, national origin, sex, religion, age or disability. Resumes will not be acceptedin lieu of applications. This application becomes public record and is subject to disclosure in accordance with the Public Information Act.NAME Social Security No. - -(Last) (First) (Middle)MAILING ADDRESS ___ __ ( ) _______________________(Street) (City) (State) (Zip) (County) Home PhoneE-MAIL ADDRESS __ ____________________________________________________________ ( ) _______________________Home FAXList any other names used if different from name on this application _________________________ ( ) _______________________Work PhoneDate of Birth / / Are you a Texas Resident? Yes No ( ) _______________________Work FAXHave you ever been adjudged mentally incompetent by a court? Yes NoHow did you learn of this appointment? Friend Professional Association or School If so, which one __________________________Have you ever been convicted of a felony or subjected to a deferred adjudication on a felony charge? Yes NoIf your answer is “Yes,” explain in concise detail on a separate sheet of paper, giving the dates and nature of the offense, the name and location of the court, andthe disposition of the case(s). A conviction may not disqualify you, but a false statement will. This agency may require additional information related toconvictions of misdemeanors._________________________________________________________________________________________________________________________________________EDUCATION (NOTE: Applicants may be required to provide proof of diploma, degree, transcripts, licenses, certifications and registrations).Circle Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12TypesofSchoolName and Locationof SchoolDates AttendedFromToMonth Year Month YearDateGraduatedExpectedGraduationDateSemester/ClockHoursCompletedType ofDiploma orDegreeMajor/MinorFields ofStudyUndergraduateColleges orUniversitiesGraduateSchoolsTechnicalVocational, orBusinessSchoolsLICENSE/CERTIFICATION (Please list all licenses/certifications held)License / Certification(RDH., RN, Attorney, CDA, etc.)DateIssuedDateExpiredIssued By/Location of Issuing Authority(State or other authority) (City and State)LicenseNumberMEMBERSHIPS (Professional, Technical, or other bodies)Organization Title/Position Organization Title/Position

Dental Hygiene Western Regional Examining Board Appointment Application 2NAME: _________ ______________ __________ ___ - - ___Last First Middle Social Security NumberVOLUNTEER EXPERIENCE(Do you possess any previous, or ongoing volunteer experience?)Organization Title/Position Organization Title/PositionEMPLOYMENT HISTORYInclude ALL employment within the last five (5) years. Begin with your current or last position and work back to your first. Employment historyshould include each position held even those with the same employer. Employer Address must include a complete mailing address, including zipcode.Position Title:Employer:Mailing Address:City, State, Zip:Employer’s Telephone Number: ( )Starting DateLeaving DateMonth Day Year Month Day YearReason for Leaving:Immediate Supervisor’s Name:Immediate Supervisor’sTelephone No.( )Type of PracticeSetting(General, Perio, Pedo, etc.)Average Numberof Hours WorkedPer Week:Position Title:Employer:Mailing Address:City, State, Zip:Employer’s Telephone Number: ( )Starting DateLeaving DateMonth Day Year Month Day YearReason for Leaving:Immediate Supervisor’s Name:Immediate Supervisor’sTelephone No.( )Type of PracticeSetting(General, Perio, Pedo, etc.)Average Numberof Hours WorkedPer Week:Position Title:Employer:Mailing Address:City, State, Zip:Employer’s Telephone Number: ( )Immediate Supervisor’s Name:Type of PracticeSetting(General, Perio, Pedo, etc.)Starting DateLeaving DateMonth Day Year Month Day YearReason for Leaving:Immediate Supervisor’sTelephone No.( )Average Numberof Hours WorkedPer Week:Position Title:Employer:Mailing Address:City, State, Zip:Employer’s Telephone Number: ( )Immediate Supervisor’s Name:Type of PracticeSetting(General, Perio, Pedo, etc.)Starting DateLeaving DateMonth Day Year Month Day YearReason for Leaving:Immediate Supervisor’s Telephone No.( )Average Numberof Hours WorkedPer Week:Position Title:Employer:Mailing Address:City, State, Zip:Employer’s Telephone Number: ( )Starting DateLeaving DateMonth Day Year Month Day YearReason for Leaving:Immediate Supervisor’s Name:Immediate Supervisor’sTelephone No.( )Type of PracticeSetting(General, Perio, Pedo, etc.)Average Numberof Hours WorkedPer Week:

Dental Hygiene Western Regional Examining Board Appointment Application 3NAME: _________ ______________ __________ ___ - - ___Last First Middle Social Security NumberREFERENCESList the Name, Address and Telephone Number of five (5) references who are not relatives or former employers.Full Name Complete Address Telephone Relationship( )( )( )( )( )MISCELLANEOUS INFORMATION1. Have you or your spouse ever been registered as a lobbyist or received compensationto present someone before a local, state, or federal government?Self or Spouse Entity Represented Entity Lobbied DatesYesNo2. Are you or your spouse related to a local, state, or federal public official? Yes NoName of Official and TitleRelationship3. To the best of your knowledge, has any federal, state, or local law enforcementor regulatory agency (on behalf of itself or any other person or entity) filed orinvestigated any grievance or complaint against you, your spouse, or an entity inwhich you have a material interest, or have you ever been a party to a civil actionor participated in activities that might create a conflict of interest?Agency Date Details and DispositionYesNo4. To the best of your knowledge, have you, your spouse, or any company inwhich you have a material interest been investigated, reprimanded, fined orsuspended from doing business with any state or federal agency?Agency Date Details and DispositionYesNo5. Do you currently serve, or have ever served, on any local, state or federalgovernment board, commission or committee or in any elected appointed office? Yes NoEntity Position Dates Compensated Reimbursed

Dental Hygiene Western Regional Examining Board Appointment Application 4NAME: _________ ______________ __________ ___ - - ___Last First Middle Social Security NumberSTATEMENT OF INTERESTPlease state why you are interested in serving as a WREB Examiner. (Please print or type your response)PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOURUNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED1. I Certify that all the information provided by me in connection with my application, whether on this document ornot, is true and complete, and I understand that any misstatement, falsification, or omission may be grounds forrefusal to be appointed, if appointed, termination.2. I understand that as a condition of appointment, I will be required to provide legal proof of authorization to work inthe U.S.3. I understand that some state agencies will check with the Texas Department of Public Safety, the Federal Bureau ofInvestigation or other organizations, for any criminal history in accordance with applicable statues.4. I authorize any of the persons or organizations referenced in this application to give you any and all informationconcerning my previous employment, education, or any other information they might have, personal or otherwise,with regard to any of the subjects covered by this application, and I release all such parties from all liability fromany damages which may result from furnishing such information to you.5. I understand that disclosure of my Social Security Number (SSN) is optional. The agency to which I am applyingmay use the SSN for administrative tracking purposes and for identification of individuals. This is in accordancewith the Federal Law U.S.C. 662a Section 7(b).THIS APPLICATION MUST BE SIGNEDSignHere ___________________________________ _____________Signature – ApplicantDate