Get Dental Intern Limited License Re-application Applicant ... - Mass.gov - Mass

This guide provides clear, step-by-step instructions for users seeking to complete the Dental Intern Limited License Re-application Applicant form in Massachusetts. Whether you are familiar with online applications or new to the process, this resource is designed to support your application journey.

Follow the steps to complete your re-application successfully.

1. Press the ‘Get Form’ button to obtain the Dental Intern Limited License Re-application Applicant form, making it accessible for online completion.
2. Enter your applicant name in the designated field, ensuring that you provide your last, first, and middle names accurately.
3. If applicable, indicate your maiden name or any other name you may have used in the space provided.
4. Provide your address of record, which can be home or business. Remember, this information is public, so ensure its accuracy.
5. Complete the section for your most recent previous address, if relevant.
6. Fill in your telephone number details, including day and cell phone numbers, and your email address for communication purposes.
7. Provide your date and place of birth, including eye color, height, and weight, along with your mother's maiden name.
8. Disclose your social security number, as required by law. This is mandatory for tax-related compliance.
9. Complete the education section by indicating if you have successfully completed all sections of an approved state or regional board examination, along with the date.
10. Certify your compliance with continuing education requirements by signing and providing your name and the supervising dentist's signature.
11. List all professional licenses or registrations you hold, or indicate that you have never held one. Attach the official verification for each license.
12. Fill in the information for your practice locations, including the name of the sponsoring institution or clinic, address, phone number, and start date.
13. Answer the good moral character questions honestly. Attach additional sheets for explanations if you answer 'yes' to any of these questions.
14. Sign the release section, authorizing the necessary institutions and organizations to share information with the Board as part of your application.
15. Complete the affidavit, certifying that all information provided is truthful and complete.
16. Finally, submit the form along with your $90 non-refundable fee, which can be made via check or money order, and ensure all attachments are included.
17. After completing your form, you may save changes, download, print, or share the completed form for your records.

Begin your re-application process online now to ensure your eligibility for a Dental Intern Limited License.