Fillable Emeritus Active Licensure Status Application (Minnesota)

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Emeritus Active Licensure Status Application (Minnesota)

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The Emeritus Active Licensure Status Application (Minnesota) form is 2 pages long and contains:

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  • 23 check-boxes
  • 18 other fields

Country of origin: US
File type: PDF

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Minnesota Board of Dentistry
2829 University Avenue SE, Suite 450
Minneapolis, MN 55414
Office: (612) 617-2250
MN Relay Service: (800) 627-3529
www.mn.gov/boards/dentistry
Emeritus Active Licensure Status Application
Non-refundable Fee
Please select your license type:
___ DDS ($212) ___ DT ($100) ___ DH ($75) ___ LDA ($55)
***PLEASE TYPE OR PRINT IN INK***
1. BACKGROUND
A. ____________________________________________________________________________________
First name
Middle name Last name
B. ____________________________________________________________________________________
Mailing address City, state, zip code
C. ____________________________________________________________________________________
Telephone (including area code) Email address (required)
D. ____________________________________________________________________________________
Primary practice address (required if employed) City, state, zip code
E. ____________________________________________________________________________________
Practice telephone (including area code) Practice email address
F. ____________________________________________________________________________________
Gender Birthdate (XX/XX/XXXX) Social Security Number (XXX-XX-XXXX)
G. ____________________________________________________________________________________
License Number(s) Original Issue Date
H. ____________________________________________________________________________________
Other names used and reason for change
2. PROFESSIONAL BACKGROUND
A. Have you ever been licensed as a dental professional outside of the State of Minnesota?
Select one: _____No _____Yes
If you selected no, you do not need to complete 2B. Continue to number 3.
If you selected yes, you must complete 2B. Once completed, continue to number 3.
B. List each state and or country in which you are or have been license as a dental professional.
____________________________________________________________________________________
____________________________________________________________________________________
M
F
X
Page 2 of 3
3. DISCLOSURES (The following questions apply to actions in Minnesota and all other jurisdictions during
or since your most recent Minnesota dental renewal.)
Yes
No
1. Have you ever been suspended from practice, reprimanded,
censured or otherwise disciplined or disqualified as a dental or
other professional?
2. Have you been convicted or adjudicated of a felony, gross
misdemeanor or misdemeanor?
3. Do you have any criminal charges pending against you?
4. Are there any unsatisfied judgments against you that resulted
from the practice of dentistry?
5. Do you have any diagnosed and/or treated mental, physical, or
cognitive condition or illness that could affect your ability to
practice with reasonable skill and safety that has not been
reported to HPSP since your last renewal?
6. Professional Development:
I attest that I have or will have completed the requirements of a
minimally acceptable Professional Development portfolio by the
expiration date of my renewal cycle.
7. Do you have any diagnosed and/or treated substance use disorder
that may affect your ability to practice with reasonable skill and
safety that has not been reported to HPSP since your last
renewal?
4. ATTESTATIONS
A. I attest that I will complete the required amount of continuing education credits per biennial cycle to
maintain Emeritus active license status requirements.
• Courses in two different CORE subject areas
• Mandatory Infection Control
• DDS/ DT’s- At least 15 fundamental credits and no more than 10 elective credits=25 total
• LDA/DH- At least 7 fundamental credits and no more than 6 elective credits=13 total
B. I attest that I will abide by the practice activities allowed under the emeritus active license.
• Pro-bono or volunteer dental practice
• Paid practice not to exceed 500 hours per year and for the purpose of providing licensing
supervision for allied professions (DDS and DT only)
• Paid consulting services not to exceed 500 hours per year
Page 3 of 3
C. I attest that I am the person referred to in this application. I understand that including false information
or false documentation in this application may result in the penalty of perjury. I understand that
falsifying information to attain licensure is a gross misdemeanor and violates the Dental Practice Act.
I attest that the entirety of this application and the attached materials are true and correct. I authorize
all persons and organizations to release any requested information, files, or records in connection with
this application to the Minnesota Board of Dentistry.
I attest that I am retired from active practice in the State of Minnesota and I am not under any current
actions with the Minnesota Board of Dentistry. I understand Minnesota Statute 150A.06 Subdivision 11
and I am aware I will need to renew my Emeritus Active License biennially and complete the CE
requirements.
_____________________________________________________________________________________
Applicant name (print) Applicant signature Date
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Completed 18 November 2020

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