Request for Certification of California Dental License
Non-Refundable Fee: $50.00
Enclose personal check or money order
For Office Use Only
Amount
Receipt
File #
Received Date
Name (first, middle, last)
Telephone Number
License Number
Address to which you wish the certificate sent:
DECLARATION: I authorize the Dental Board of California to send a certification of my
California dental license to the address above.
Signature Date
Complete this section only if exam score is required.
DECLARATION I authorize the Dental Board of California to disclose the scores from my
California dental license examination to the address above within 60 days of the date of my
signature.
Signature Date
__________________
__________________
____________________
_____________
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. Failure to provide all or any part of the requested information will result in the
rejection of the request as incomplete. Each individual has the right to review the personal information maintained
by the agency unless the records are exempt from disclosure.
LIC-22 (10/17)
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
DENTAL BOARD OF CALIFORNIA
2005 Evergreen St., Suite 1550, Sacramento, CA 95815
P (916) 263-2300 | F (916) 263-2140 | www.dbc.ca.gov
. I
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