Sts seeking reinstatement of their licenses from retirement or suspension for failure to renew, will be required to submit the following information: 1. A completed application (enclosed). 2. A detailed resume of your dental hygiene practice since your retirement/suspension or military exemption. Dental Hygiene applicants who have not practiced for five or more years are required to take a refresher course. 3. A check in the amount of $105/retired dental hygienist, or $136/suspended hygieni.
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How to fill out the OH DEN1003 online
This guide provides a comprehensive overview of the OH DEN1003 application for reinstatement of dental hygiene licenses in Ohio. It offers clear, step-by-step instructions tailored to help you navigate the process smoothly.
Follow the steps to successfully complete the OH DEN1003 form.
- Click ‘Get Form’ button to access the OH DEN1003 application and open it in your preferred online editing tool.
- Fill in your present legal name. Ensure that you print your first, middle, and last names as well as any maiden names if applicable.
- Provide your address, including your street number, city, state, and zip code, ensuring all information is accurate.
- Input your telephone numbers — both home and business — clearly stating the respective numbers.
- Enter your Social Security number in the specified field, following the instructions about confidentiality.
- Specify your intended place of practice, including the street address, city, state, and zip code.
- List any other state licenses you hold, detailing the jurisdiction, license number, date of issuance, years of practice, and method of licensure.
- Respond to questions regarding any refusals of licensure, disqualifications, or disciplinary actions. Attach necessary statements if you answer 'yes' to certain conditions.
- Complete the criminal history section, disclosing any felony or misdemeanor convictions and any pending criminal charges.
- Submit required documentation such as proof of continuing education, a criminal records check, and immunization records against hepatitis B.
- Ensure that two licensed dentists complete the Certificates of Good Moral Character to affirm your qualifications.
- Review the entire application for accuracy and completeness before submitting it. Save your changes, download, or print a copy of the completed form.
Take the next step towards reinstating your dental hygiene license by completing the OH DEN1003 form online today.
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