NAC631.2207. Application for limited license to supervise courses of continuing education.

An applicant for a limited license to supervise courses of continuing education involving live patients at a registered facility must provide the following information and documentation in his or her application:

     1. The date and place of his or her birth;

     2. Certification of graduation from an accredited dental school or college or from an accredited school or college of dental hygiene, whichever is applicable;

     3. Whether the applicant has applied for similar licensure in another state or territory of the United States or the District of Columbia and, if so, the name of the state or territory or the District of Columbia, the date and the result of the application;

     4. If the applicant has practiced dentistry or dental hygiene in another state or territory of the United States or the District of Columbia, certification from the licensing authority of each state or territory or the District of Columbia in which the applicant has practiced or is practicing that the applicant is in good standing and that there are not any disciplinary proceedings pending against the applicant in the other state or territory or the District of Columbia which may affect his or her standing;

     5. Whether the applicant has terminated or attempted to terminate a license from another state or territory of the United States or the District of Columbia and, if so, his or her reasons for doing so;

     6. If the applicant is not a natural born citizen of the United States, a copy of his or her certificate of naturalization or other document attesting that the applicant is legally eligible to reside and work in the United States;

     7. Whether the applicant has ever been convicted of a crime involving moral turpitude or has entered a plea of nolo contendere to a charge of such a crime and, if so, the date and place of the conviction or plea and the sentence, if any, which was imposed;

     8. Whether the applicant has had any misdemeanor or felony convictions and, if so, any documents relevant to the misdemeanor or felony convictions;

     9. Whether any malpractice judgment has been entered against the applicant and, if so, any documents relevant to the malpractice judgment;

     10. Whether the applicant has a history of substance abuse and, if so, any documents relevant to the substance abuse;

     11. Whether the applicant has been refused permission to take an examination for licensure by any other state or territory of the United States or the District of Columbia and, if so, any documents relevant to the refusal;

     12. Whether the applicant has been denied licensure by this State, any other state or territory of the United States, or the District of Columbia, and, if so, any documents relevant to the denial;

     13. Whether the applicant has had his or her license to practice dentistry or dental hygiene suspended, revoked or placed on probation in this State, another state or territory of the United States, or the District of Columbia, and, if so, any documents relevant to the suspension, revocation or probation;

     14. Whether the applicant’s practice of dentistry or dental hygiene has been subject to mandatory supervision in this State, another state or territory of the United States, or the District of Columbia, and, if so, any documents relevant to the mandatory supervision;

     15. Whether the applicant has received a public reprimand or is currently involved in any disciplinary action concerning his or her license to practice dentistry or dental hygiene in this State, another state or territory of the United States, or the District of Columbia and, if so, any documents relevant to the reprimand or disciplinary action; and

     16. Two sets of certified fingerprint cards and an authorization form allowing the Board to submit the fingerprint forms to law enforcement agencies for verification of background information.

     (Added to NAC by Bd. of Dental Exam’rs by R200-09, eff. 8-13-2010)