Section 828IAC5-1-1. Application

   (a) Applicants for licensure as an instructor under IC 25-14-1-27.5 shall apply in the manner required by the board and shall submit the fee required by 828 IAC 0.5-2-3.

  (b) The applicant for an instructor's license shall provide the following:

(1) Where the name on any document differs from the applicant's name, a notarized or certified copy of a marriage certificate or legal proof of name change.

(2) Proof that the applicant has been approved under the credentialing process of an Indiana school of dentistry or an affiliated medical center of an Indiana school of dentistry as required under IC 25-14-1-27.5. The proof shall include a notarized statement of approval submitted by an Indiana school of dentistry or an affiliated medical center of an Indiana school of dentistry and copies of all documentation reviewed by the school or affiliated medical center in determining its approval of the applicant.

(3) Documentation or a demonstration of clinical and academic competency, which shall include the following:

(A) If the applicant is a graduate of a school of dentistry outside the United States, its possessions, or Canada, the applicant must submit an original transcript of the applicant's dental education, including the degree conferred and the date the degree was conferred. If the original transcript is in a language other than English, the applicant must include a certified translation of the transcript. If an original transcript is not available, the applicant must submit the following:

(i) A notarized or certified copy of the original dental school transcript, which must include the degree conferred and the date the degree was conferred.

(ii) An affidavit fully and clearly stating the reasons that an original transcript is not available.

(B) If the applicant has taken the National Board Dental Examination provided by the Joint Commission on Dental Examinations or has taken the National Dental Examining Board of Canada Written Examination provided by the National Dental Examining Board of Canada, the applicant shall submit proof of having taken the examination and the results thereof.

(C) If the applicant has taken a clinical licensing examination in any other state, country, territory, or recognized jurisdiction, the applicant shall submit proof of having taken the examination and the results thereof.

(4) If the applicant has been convicted of a criminal offense, excluding minor traffic violations, a notarized statement detailing all criminal offenses, excluding minor traffic violations, for which the applicant has been convicted. This notarized statement must include the following:

(A) The offense of which the applicant was convicted.

(B) The court in which the applicant was convicted.

(C) The cause number under which the applicant was convicted.

(D) The penalty imposed by the court.

(5) An applicant who is now, or has been, licensed to practice any health profession in another state within the United States, or in any other country, territory, or recognized jurisdiction must submit verification of license status. This information must be sent by the state, country, territory, or other recognized jurisdiction that issued the license directly to the Indiana board.

(6) A self-query form completed by the National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) data bank.

(7) Proof of completion of at least twenty (20) hours of continuing dental education in dentistry taken in the previous two (2) years. No more than two (2) hours of training in basic life support shall count toward this requirement. Practice management courses will not be accepted.

(8) Graduates of a school of dentistry outside of the United States in which the instruction was conducted in a language other than English shall submit proof of having passed the Test of English as a Foreign Language (TOEFL).

(9) Proof that the applicant has been licensed or has had the equivalent of a license to practice dentistry in the United States or in any country, territory, or other recognized jurisdiction for not less than five (5) years out of the nine (9) years immediately preceding the submission of the application.

(10) Proof that the applicant is currently certified in basic life support or advanced cardiac life support.

  (c) The applicant shall certify that the applicant will teach and practice dentistry only at or on behalf of an Indiana school of dentistry or an affiliated medical center of an Indiana school of dentistry. The applicant shall further certify that the applicant will not engage in the private practice of dentistry.

  (d) All information on the application shall be submitted under oath or affirmation, subject to the penalties for perjury. (State Board of Dentistry; 828 IAC 5-1-1; filed Apr 18, 2005, 2:00 p.m.: 28 IR 2713; readopted filed Nov 22, 2011, 12:15 p.m.: 20111221-IR-828110366RFA)