Yes NoYes No
19. Have you ever been the subject of a malpractice settlement or judgment?
If yes, provide a detailed explanation of the circumstances and outcomes relating
to the malpractice settlement or judgment. You may be required to provide additional
Yes No
information after review of your explanation.
IMPORTANT REQUIREMENT: If a disciplinary action is filed against any license you currently hold pending the
Board’s decision on this application for a dental license, you must notify the Board in writing within 48 hours.
20. Do you have a permit to prescribe controlled substances from the Federal Drug
Enforcement Agency (DEA)?
Yes No
If yes, enter DEA number:
21. Has permission from the DEA to prescribe controlled substances ever been suspended,
revoked or denied?
Yes No
If yes, provide a detailed explanation of the circumstances and a copy of the
document(s).
NOTE: A license will not be issued until clearance has been received from the California Department of Justice
and the Federal Bureau of Investigation. See Instructions for fingerprinting.
DECLARATION
I am the applicant for Licensure by Credential referred to in this application. I have carefully read
the questions in the foregoing application and have answered them truthfully, fully, and
completely.
My signature on this application, or copy thereof, authorizes the National Practitioner Data Bank and
the Federal Drug Enforcement Agency to release any and all information required by the Dental Board
of California.
I certify under penalty of perjury under the laws of the State of California and automatic forfeiture of my
California dental license if one is issued that the information I provided to the Board in this application is true
and correct to the best of my knowledge and belief.
Date Signature of Applicant
INFORMATION COLLECTION AND ACCESS The information requested herein is mandatory and is
maintained by Dental Board of California, 2005 Evergreen Street, Suite 1550 Sacramento, CA. 95815,
Executive Officer, 916-263-2300, in accordance with Business & Professions Code, §1600 et seq. Except for
Social Security numbers, the information requested will be used to determine eligibility. Failure to provide all or
any part of the requested information will result in the rejection of the application as incomplete. Disclosure of
your Social Security number is mandatory and collection is authorized by §30 of the Business & Professions
Code and Pub. L 94-455 (42 U.S.C.A. §405(c)(2)(C)). Your Social Security number will be used exclusively for
tax enforcement purposes, for compliance with any judgment or order for family support in accordance with
Section 17520 of the Family Code, or for verification of licensure or examination status by a licensing or
examination board, and where licensing is reciprocal with the requesting state. If you fail to disclose your
Social Security number, you may be reported to the Franchise Tax Board and be assessed a penalty of $100.
Each individual has the right to review the personal information maintained by the agency unless the records
are exempt from disclosure. Applicants are advised that the names(s) and address(es) submitted may, under
limited circumstances, be made public.
LBC-1 05/20
