A2. 

Refer to Georgia Law O.C.G.A § 43-11-71-.1 and Board Rule 150-7-.05

• *APPLICATION - Found on the board’s web-site (http://sos.georgia.gov/plb/dentistry/) under the link for Online Services/Download Forms. 
• *NOTARIZED APPLICATION: Completed application form accompanied by a fee of $1,025.00. Your application will not be processed unless the fee and all supporting documents are received.
• *LICENSE VERIFICATION: Official licensure verifications for every dental license ever held. Each letter must indicate the date of licensure, the licensure status (active, inactive, expired, or revoked, etc.) standing of license, any disciplinary charges made against you by the licensing board or by any other state agency, and the result of these actions. The applicant must provide a copy of the formal complaint/pleading, outcomes, and a personal written explanation for each instance of discipline. You should call each state board about fees for these services. The verification must be submitted with your application IN THE ORIGINAL SEALEDENVELOPE FROM THE BOARD OF EACH LICENSING STATE, and must be dated within four months of Board receipt of your complete application packet.
• *DEGREE TRANSCRIPT: : An Official Transcript which documents graduation with a A.S.,B.A., or B.S. degree from a dental hygiene school which is accredited by the American Dental Association Commission on Dental Education. The transcript must be IN THE ORIGINAL SEALED ENVELOPE FROM THE COLLEGE. Graduates from a non-accredited school are ineligible.
• *NATIONAL BOARD SCORES: National Board Scores from the ADA Joint Commission on National Dental examinations. The ADA (1-800-621-8099) will send a copy of National Board scores to state licensure boards only. If you ask the ADA to send our board a copy of your National Board scores, so indicate in your application packet. Please do not submit the National Board Certificate.  Your scores must come directly from the ADA to the Board Office. 
• *CLINICAL EXAMINATION: Certification that the applicant has successfully passed a clinical examination that is approved by the Board.
• *JURISPRUDENCE EXAMINATION: The examination must be downloaded from our website- http://sos.georgia.gov/plb/dentistry/ (Application Downloads link). The study materials are also on our website. The fee for this examination is $25.00, payable to the order of Georgia Board of Dentistry. FEES ARE NON REFUNDABLE. A score of 75 or higher is considered a passing score.
• *NATIONAL PRACTITIONER DATA BANK: A National Practitioner Data Bank (NPDB) certified report of any pending or final disciplinary actions or malpractice actions against any license ever held by the applicant in any state. All applicants must submit a NPDB report along with a completed application. (NPDB must be dated within four months). The ONLY applicants exempted from the requirement of NPDB report submission are those applicants within 6 months of dental school graduation who have never been issued a dental license in any state or U.S. territory. The NPDB report must be received in the ORIGINAL SEALED ENVELOPE FROM NPDB. Those applications which have any disciplinary or malpractice case(s) (open & closed) will be considered for licensure on a case by case basis, after receipt of all required application materials. For each case, the applicant must submit: 1) a copy of the formal complaint pleadings filed by the plaintiff/complainant or State Regulatory Agency, 2) a copy of the final action, disposition, or settlement, 3) a personal explanation of the disciplinary action or the malpractice claim, and 4) any further information requested by the Board in separate communications. To obtain information (self-query) from the NPDB-HIPDB, please visit www.npdb-hipdb.com, scroll to the right side of the home page, and click Perform a Self-Query. The self-query is $20.00, payable by credit card (VISA, MasterCard, Discover, or American Express). If you do not have Internet access, contact the Customer Service Center at 1-800-767-6732 from 8:30 a.m. to 6:00 p.m. Eastern Time (8:30 a.m. to 5:30 p.m. Fridays).
• *CRIMINAL HISTORY INFORMATION:  If you have ever been summoned, arrested, taken into custody, indicted, convicted or tried for, or charged with, or pled guilty to, or pled, nolo contender to, a violation of any law or ordinance or the commission of any felony or misdemeanor (excluding minor traffic violations), (DWI & DUI are not minor traffic violations), or if you have been requested to appear before a prosecuting attorney or investigative agency in any matter you must attach the court disposition.  Although a conviction may have been expunged from the records by a court order, it nevertheless must be disclosed on your application.  For each occurrence furnish a written statement giving the complete facts in your own words, including in the statement the date, name and nature of the offense, the name and locality of the court, and the disposition of each such matter.
• *CPR: Submit a photocopy of your current CPR certification pursuant to Board Rule 150-5-.04.
• EMPLOYMENT AFFIDAVIT: An affidavit from the applicant stating for the two years immediately preceding application: (A) the dates and locations where the applicant has practiced dental hygiene and (B) that the applicant has been in full time clinical practice of a minimum of 1,000 hours per year in the hands-on treatment of patients. Please note that the practice requirement cannot be waived as it is required by law.
• LETTER FROM EMPLOYER: Submit a letter from your employer(s) verifying employment and that you have been in full time clinical practice for a minimum of 1,000 hour per year in the hands-on treatment of patients.
• MALPRACTICE QUESTIONNAIRE: Complete one for each suit and attach the necessary documentation. (If not applicable, write N/A on the form sign, date, and return with application).
• •*COPY OF COURT DOCUMENT OR AFFIDAVIT explaining any discrepancies of the applicant’s name if documents submitted bear different name(s).[i.e. marriage certificate, divorce decree, legal name change] .

ALL dental hygiene licensure by credential applications MUST BE APPROVED by the Board