Fillable Resident Permit Application Instructions/Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Resident Permit Application Instructions/Checklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Resident Permit Application Instructions/Checklist
Use this checklist to determine whether you have complied with all of the requirements. Once your application has been received, a le
will be established and you will be notied if any documents are missing.
Permit Fee: $10.00
Answer all of the questions on the application form.
Please provide the address information for your Residency Program as the Business Address on page 1. Also, remember to
include the dates of your residency at this location.
Staple one passport-style photograph of your head and shoulders to the front page of the application. Please sign and print your
name along with the date on the back of the photo.
Enter your Social Security number.
Have your dental school(s) provide an ofcial school transcript in a sealed envelope. Do not open the envelope. Attach each
sealed transcript(s) to the application, or arrange to have the school(s) forward the transcript(s) directly to the Board ofce.
List the date that each exam was taken in the Examination History section, if applicable
Please provide your DENTPIN (Dental Personal Identication Number) number so the Board may obtain your scores from the
National Board Exam. Also, be sure to request that your scores be sent/released to New Jersey electronically.
Please use additional paper if you cannot t all of your information in the space provided on this form. Make a notation by
each question that more information has been attached. Please mark your attached answers with the same number corresponding
to the question that you are answering.
If you answered “Yes,” to any of the child support questions, please attach to this application an explanation written on a separate
sheet of paper.
Fill out the Medical Conditions section on this application.
Once the entire application has been completed, have it signed and stamped by a Notary Public.
Notice: Any applicant ling an application after November 22, 2003, will be subject to a criminal history background check pursuant
to P.L. 2002, Chapter 104. Information will be provided to applicants under separate cover.
New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor, P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
Application for a Resident Permit
Date: _______________________________
A fee of $10 in the form of a check or money order made out to the State of New Jersey, must be submitted with
this application. (Applicants should understand that if the fees are paid with a personal check, and the check is returned by the bank due
to insufcient funds, the next step in the licensure process will be delayed until the fees are paid.)
The Division is precluded by law from disclosing to the public the place of residence of licensees or applicants, without their
consent. However, you are required to provide an address that may be released to the public in our directories or in response to
other requests (by putting a check in the appropriate box). If you provide your place of residence as your public address
of record, we will assume that you have consented to have that address be disclosed. If you do not consent to the disclosure of
your place of residence, you should provide an address of record other than your place of residence that may be released
to the public. One of your addresses must include a street, city, state and ZIP code.
Information that you provide on this application may be subject to public disclosure as required by the Open Public Records Act (OPRA).
Please print clearly. You must answer all of the questions on this application.
Personal Information Date of birth: _________________________
Month Day Year
Mr.
1. Name Mrs. ________________________________________________________________ ( _______________________)
Ms.
Last name First name Middle initial Maiden name
2. Address
Home: _______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_____________________________________ ___________________________________
Telephone number (include area code) E-mail address
Business: _____________________________________________________________________________________________
Name of Residency Program Telephone number (include area code)
____________________________________________________________________________________________
Street City State ZIP code County
Dates of Residency ___________________________________ to _______________________________________
Mailing: ______________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Staple a clear, full-face passport-
style photograph (2˝x 2˝) of your
head and shoulders, taken within
the past six months.
A photo is required with each
application.
For ofce use only
Application number:
________________________
Check or money order:
________________________
Date processed:
________________________
License number:
________________________
- 1 -
3. Social Security
You must provide your Social Security number to the Board or Committee. Failure to do so will result in denial/nonrenewal of
licensure or certication.
*Social Security Number: ______ - ______- _______
*Pursuant to N.J.S.A. 54:50-24 et. seq. of the New Jersey taxation law, N.J.S.A. 2A:17-56.44e of the New Jersey Child Support
Enforcement Law, Section 1128E(b)(2)A of the Social Security Act and 45 C.F.R. 60.7,60.8 and 60.9, the Board is required to
obtain your Social Security number. Pursuant to these authorities, the Board is also obligated to provide your Social Security
number to:
a. the Director of Taxation to assist in the administration and enforcement of any tax law, including for the purpose of reviewing
compliance with State tax law and updating and correcting tax records,
b. the Probation Division or any other agency responsible for child support enforcement, upon request, and
c. the National Practitioner Data Bank and the HIP Data Bank, when reporting adverse actions relating to health care
professionals.
4. Citizenship / Immigration Status
Federal law limits the issuance or renewal of professional or occupational licenses or certicates to U.S. citizens or qualied aliens.
To comply with this federal law, check the appropriate box below which indicates your citizenship/immigration status. If you are not
a U.S. citizen, attach a copy of your alien registration card (front and back) or other documentation issued by the ofce of U.S.
Citizenship and Immigration Services (USCIS).
U.S. citizen
Alien lawfully admitted for permanent residence in U.S.
Other immigration status
Questions about your immigration status and whether or not it is a qualifying status under federal law should be directed to the
USCIS at: 1-800-375-5283.
Education
5. Undergraduate education______________________________Year graduated______________ Degree obtained ____________
College or university
6. Please list each dental school attended, using a separate sheet of paper if necessary.
Attach a sealed ofcial dental school transcript from each school(s) listed below.
Months and Years Dental School City, State, County
___ / ___ to ___ / ___ ______________________________ ______________________________
___ / ___ to ___ / ___ ______________________________ ______________________________
___ / ___ to ___ / ___ ______________________________ ______________________________
I received the degree of __________________________________ on the ________ day of ___________________ , ________
Month Year
- 2 -
7. List in chronological order any employment, residencies or postgraduate training you have acquired or participated in since your
graduation from dental school. (Please account for all of the years since graduation and include addresses and dates. Use additional
sheets of paper if necessary.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8. Have you ever taken a state board or regional board examination and failed? Yes No
9. Please list below the date each test was taken and passed.
a. A.D.E.X. __________________________________
b. National Board Exam DENTPIN number ____________________________
c. N.J. Law and Jurisprudence Exam (If taken) _______________
d. If you are applying for reciprocal licensure, list the other state(s) and/or regional clinical exam(s) you have taken, and the
date(s) you passed the exam.
____________________________________________ ____________________________
Exam (indicate state or jurisdiction) Date
____________________________________________ ____________________________
Exam (indicate state or jurisdiction) Date
10. Have you previously applied for a license as a dentist in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
If “Yes,” when and where? _________________________________________________
11. Do you currently hold, or have you ever held a professional license of any kind in New Jersey, any other state, the District of
Columbia or in any other jurisdiction? Yes No
If “Yes,” for each license held, provide the date(s) held and the number(s). If the license was issued under a different name, please
provide that name. __________________________________________________________________________________
Last name First name Middle initial
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
____________________________ ____________________ _________________________ ___________________
State or jurisdiction that issued the license or certicate Type of license or certicate Number Date issued/expired
- 3 -
12. Have you ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted into pre-trial intervention
(P.T.I.); pled guilty to any violation of law, ordinance, felony, misdemeanor or disorderly persons offense, in this or any other state
or in a foreign country? (Parking or speeding violations need not be disclosed, but motor vehicle violations such as driving while
impaired or intoxicated must be.) Yes No
13. Have you ever been convicted of any crime or offense under any circumstances such as, but not limited to, a plea of guilty, non vult,
nolo contendere, no contest, etc., or a nding of guilt by a judge or jury?
Yes No
14. Have you ever been disciplined or denied a dental license or any other professional license in New Jersey, any other state, the
District of Columbia or in any other jurisdiction?
Yes No
15. Have you ever had a professional license or certicate of any type suspended, revoked or surrendered in New Jersey, any other
state, the District of Columbia or in any other jurisdiction? Yes No
16. Do you hold a current D.E.A. registration? Yes No
If “Yes,” has this registration ever been suspended or revoked?
Yes No
17. Has any action (including the assessment of nes or other penalties) ever been taken against your professional practice by any
agency or certication board in New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
18. Have you ever been named as a defendant in any litigation related to the practice of dentistry or other professional practice in
New Jersey, any other state, the District of Columbia or in any other jurisdiction?
Yes No
19. Are you aware of any investigation pending against a professional license issued to you by a professional board in New Jersey,
any other state, the District of Columbia or in any other jurisdiction? Yes No
20. Are there any criminal charges now pending against you in New Jersey, any other state, the District of Columbia or in any other
jurisdiction? Yes No
21. Have you ever been sanctioned by or is any action pending before any employer, association, society, or other professional group
related to the practice of dentistry or other professional practice in New Jersey, any other state, the District of Columbia or in any
other jurisdiction? Yes No
If the answer to any of the above questions, numbers 12 through 20, is “Yes,” provide a complete explanation of the
circumstances leading to the action, and any supporting documentation, on separate sheets of paper.
22. Student Loan
Are you in default in regard to any student loan obligation(s)?
Yes No
If “Yes,” you must obtain documentary evidence that you have reached an arrangement with the bank or with the entity that issued
your student loan, for the eventual repayment of the loan. You will not be able to obtain a license or certicate unless you provide the
required documents concerning the plan for repayment of your student loan.
23. Child Support
Please certify, under penalty of perjury, the following:
a. Do you currently have a child-support obligation?
Yes No
(1) If “Yes,” are you in arrears in payment of said obligation? Yes No
(2) If “Yes,” does the arrearage match or exceed the total amount payable for the past six months? Yes No
b. Have you failed to provide any court-ordered health insurance coverage during the past six months? Yes No
c. Have you failed to respond to a subpoena relating to either a paternity or child-support proceeding? Yes No
d. Are you the subject of a child-support-related arrest warrant? Yes No
In accordance with N.J.S.A. 2A:17-56.44d, an answer of “Yes” to any of the questions a(1) through d will result in a denial of
licensure or certication. Furthermore, any false certication of the above may subject you to a penalty, including, but not limited
to, immediate revocation or suspension of licensure or certication.
___________________________________ ___________________________________ _______________________
Applicant’s name (please print) Applicant’s signature Date
- 4 -
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Name of applicant (Please print) ____________________________
Medical Conditions Questions
Questions 24 through 29 pertain to medical conditions and use of chemical substances. Please read the denitions carefully. Your
responses will be treated condentially and retained separately. Please be aware that you have the right to elect not to answer those
portions of the following questions which inquire as to the illegal use of controlled dangerous substances or activity if you have
reasonable cause to believe that answering may expose you to the possibility of criminal prosecution. In that event, you may assert
the Fifth Amendment privilege against self-incrimination. Any claim of Fifth Amendment privilege must be made in good faith. If
you choose to assert the Fifth Amendment, you must do so in writing. You must fully respond to all other questions on the application.
Your application for licensure will be processed if you claim the Fifth Amendment privilege against self-incrimination. You should
be aware, however, that you may later be directed by the Attorney General to answer a question that you have refused to answer on
the basis of the Fifth Amendment, provided that the Attorney General rst grants you immunity afforded by statutory law. (N.J.S.A.
45:1-20.)
“Ability to practice dentistry” is to be construed to include all of the following:
a. The cognitive capacity to exercise reasonable dental judgments and to learn and keep abreast of professional developments;
b. The ability to communicate those judgments and related information to patients and other interested parties, with or without
the use of aids or devices, such as voice ampliers; and
c. The physical capability to perform the duties of a dentist, with or without the use of aids or devices, such as corrective lenses
or hearing aids.
“Medical Condition” includes physiological, mental or psychological conditions or disorders, such as, but not limited to orthopedic,
visual, speech and hearing impairments, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease,
diabetes, mental retardation, emotional or mental illness, specic learning disabilities, H.I.V. disease, tuberculosis, drug addiction
and alcoholism.
“Chemical substance” is to be construed to include alcohol, drugs or medications, including those taken pursuant to a valid
prescription for legitimate medical purposes and in accordance with the prescriberÕs direction, as well as those used illegally.
“Currently” does not mean on the day of, or even in the weeks or months preceding the completion of this application. Rather, it
means recently enough so that the use of drugs may have an ongoing impact on oneÕs functioning as a licensee, or within the
previous two years.
“Illegal use of controlled dangerous substance” means the use of a controlled dangerous substance obtained illegally (e.g. heroin
or cocaine) as well as the use of controlled dangerous substances which are not obtained pursuant to a valid prescription or not taken
in accordance with the directions of a licensed health care practitioner.
24. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable
skill and safety? Yes No
25. Are the limitations or impairments caused by your medical condition reduced or ameliorated because you receive ongoing
treatment (with or without medications) or participate in a monitoring program**?
Yes No Not applicable
26. Are the limitations or impairments caused by your medical condition reduced or ameliorated because of the eld of practice,
the setting or manner in which you have chosen to practice? Yes No Not applicable
27. Does your use of chemical substance(s) in any way impair or limit your ability to practice your profession with reasonable skill
and safety? Yes No Not applicable
28. Have you ever been diagnosed as having or have you ever been treated for pedophilia, exhibitionism or voyeurism?
Yes No
29. Are you currently engaged in the illegal use of controlled dangerous substances? (Recall that “currently” is dened as “within
the last two years.”) Yes No
If you answered “Yes” to question 29, are you currently participating in a supervised rehabilitation program or professional
assistance program which monitors you in order to assure that you are not engaging in the illegal use of controlled dangerous
substances? Yes No
** If you receive such ongoing treatment or participate in such a monitoring program, the Board will make an individualized
assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to determine
whether an unrestricted license or certicate should be issued, whether conditions should be imposed or whether you are not
eligible for licensure or certication.
____________________________________________________ ___________________________________
Signature of applicant Date
- 5 -
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AffidAvit
This afdavit is to be executed by the applicant before a notary public:
State of: __________________________________________________
County of: ________________________________________________
I, ________________________________________________ , in making this application to the New Jersey State Board of Dentistry for
licensure under the provisions of Title 45 of the General Statutes of New Jersey and the Rules of the New Jersey State Board of Dentistry,
swear (or afrm) that I am the applicant and that all information provided in connection with this application is true to the best of my
knowledge and belief. I understand that any omissions, inaccuracies or failure to make full disclosures may be deemed sufcient to deny
licensure or to withhold renewal of or suspend or revoke a license issued by the Board.
I further swear (or afrm) that I have read N.J.S.A. 45:6-1 et seq., together with the Rules and Regulations of the New Jersey State Board
of Dentistry, N.J.A.C. 13:30-1.1, and fully understand that in receiving licensure from the Board, I bind myself to be governed by them.
Furthermore, I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualifications for licensure. I further authorize all institutions, employers, agencies and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records requested by
the Board.
__________________________________________________
Signature of applicant
Sworn and subscribed to before me this __________________
day of ____________________________ , ______________
Month Year
__________________________________________________
Name of Notary Public (please print)
__________________________________________________
Signature of Notary Public
Do not write in this space
N.E.R.B. scores
Date received ____________________________ W.R.T.N. ___________________________
License number ____________________________ M.M.K.N. __________________________
National Board ____________________________ RESTOR ___________________________
Certication date ____________________________ PERIO _____________________________
N.E.R.B.
Certication date ____________________________
Afx Seal Here
} ss.
- 6 -
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey State Board of Dentistry
P.O. Box 45005
Newark, New Jersey 07101
(973) 504-6405
CertifiCAtion And AuthorizAtion form
for A CriminAl history BACkground CheCk
Directions: Answer all of the questions on this form.
1. Name _________________________________________________________ ( ________________________)
Last First Middle Maiden Name
2. Address ___________________________________________________________________________________________
Street or P.O. Box City State ZIP code
3. Date of birth __ __ /__ __ /__ __ Sex: Male Female
Month Day Year
4. Social Security number _________/ _____ / ________
5. Have you completed the ngerprinting process for any Board or Committee of the New Jersey Division of Consumer
Affairs since November 2003?
Yes No
If “No,” you will receive a separate mailing from the Board or Committee regarding the criminal history background process.
Please send no payment now.
If “Yes,” please provide the following information and follow the instructions outlined below:
_______________________________________________ _______________________________________________
Board or committee requiring the ngerprinting Month and year you were ngerprinted
If you were ngerprinted after November 2003 as part of the criminal history background process for licensure or
certication by any other Board or Committee of the New Jersey Division of Consumer Affairs, you will not be required
to be ngerprinted a second time. However, the Division must perform a criminal history background check each time you
apply for licensure or certication. The fee for this background check will be $18.75. Payment should be made in the form of
a check or money order payable to the State of New Jersey and should accompany your application packet.
6. Have you ever been arrested and/or convicted of a crime or offense? (Minor trafc offenses such as a parking or speeding
violations need not be listed.)
Yes No
Every such conviction on record must be disclosed. A true copy of every police report, judgment of conviction, sentencing
order and termination of probation order, if applicable, must be submitted with this form. Any documents (including employer
or supervisor letters of reference, if applicable) which present clear and convincing evidence of rehabilitation must be submitted
with this form. Failure to follow these instructions may result in the denial of an initial application.
Note: Copies of judgments, sentencing and termination of probation orders may be obtained from the clerk of the county
where those orders, disposing of the conviction, were issued and led.
Your continuing responsibility to disclose convictions of crimes or offenses: You must notify the Board or Committee
within ve (5) business days if you are convicted of any crimes or offenses after this form has been completed.
Continuation on the reverse side ➨
Board or Committee
________________________
Ofcial Use Only
Resubmit
________________________
Ofcial Use Only
Dual License
License Type 1
________________________
Applicant’s Number
________________________
License Type 2
________________________
Applicant’s Number
________________________
- 7 -
CertifiCAtion
I, ______________________________________________, in making this application to the Board or Committee for
certication or licensure, certify that I am the applicant and that all of the information provided in connection with this
application is true to the best of my knowledge and belief. I understand that any omissions, inaccuracies or failure to make full
disclosures may be deemed sufcient to deny certication or licensure or to withhold renewal of or suspend or revoke a certicate
or license issued by the Board or Committee.
I voluntarily consent to a thorough investigation of my present and past employment and other activities for
the purpose of verifying my qualications for certication or licensure. I further authorize all institutions, employers, agencies
and all governmental agencies and instrumentalities (local, state, federal or foreign) to release any information, les or records
requested by the Board or Committee.
I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment.
__________________________________________________________ _________________________________
Signature of applicant Date
Rev. 1/2/19
- 8 -
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Resident Permit Application InstructionsChecklist (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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