Fillable APPLICATION FOR ADULT ORAL CONSCIOUS SEDATION CERTIFICATE (California)

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APPLICATION FOR ADULT ORAL CONSCIOUS SEDATION CERTIFICATE (California)

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APPLICATION FOR ADULT ORAL CONSCIOUS SEDATION CERTIFICATE
FEES
Application Fee: $368.00
(Must be enclosed with application)
APPLICATION FEES
ARENON-REFUNDABLE
(PLEASE PRINT CLEARLY OR TYPE)
For Office Use Only
Rec #
FeePd
Date
Cashiered
Entity#
File #
For Office Use Only
Date Received
1. SSN/ITIN:
3. LEGAL NAME:
LAST
FIRST
MIDDLE
4. MAILING ADDRESS:
5. EMAIL ADDRESS:
6. TELEPHONE NUMBER:
7. FAX NUMBER:
8. DENTAL LICENSE:
9. QUALIFICATION – INDICATE UNDER WHICH METHOD LISTED BELOW YOU QUALIFY FOR AN ORAL
CONSCIOUS SEDATION CERTIFICATE FOR ADULTS AND ATTACH APPROPRIATE DOCUMENTATION.
SUCCESSFUL COMPLETION OF A POSTGRADUATE PROGRAM IN ORAL AND MAXILLOFACIAL SURGERY
APPROVED BY THE COMMISSION ON DENTAL ACCREDITATION OR A COMPARABLE ORGANIZATION
APPROVED BY THE BOARD. APPLICANT MUST PROVIDE A COPY OF HIS OR HER DIPLOMA.
SUCCESSFUL COMPLETION OF A PERIODONTICS OR GENERAL PRACTICE RESIDENCY OR ADVANCED
EDUCATION IN A GENERAL DENTISTRY POST-DOCTORAL PROGRAM ACCREDITED BY THE COMMISSION
ON DENTAL ACCREDITATION THAT MEETS THE DIDACTIC AND CLINICAL REQUIREMENTS OF SECTION
1044.3 OF THE BUSINESS AND PROFESSIONS CODE. APPLICANT MUST PROVIDE A COPY OF HIS OR HER
DIPLOMA.
SUCCESSFUL COMPLETION OF A BOARD-APPROVED EDUCATIONAL PROGRAM ON ORAL MEDICATIONS
AND SEDATION. APPLICANT MUST PROVIDE COMPLETED FORM OCS-2 TO DOCUMENT COMPLETION.
FORM OCS-3 11/20
10. DO ANY OF THE FOLLOWING STATEMENTS APPLY TO YOU
:
•
YOU WERE ADMITTED TO THE UNITED STATES AS A REFUGEE PURSUANT TO
SECTION 1157 OF TITLE 8 OF THE UNITED STATES CODE;
•
YOU WERE GRANTED ASYLUM BY THE SECRETARY OF HOMELAND SECURITY
OF THE UNITED STATES ATTORNEY GENERAL PURSUANT TO SECTION 1158 OF
TITLE 8 OF THE UNITED STATES CODE; OR,
•
YOU HAVE A SPECIAL IMMIGRANT VISA AND WERE GRANTED A STATUS
PURSUANT TO SECTION 1244 OF THE PUBLIC LAW 110-181, PUBLIC LAW 109-163,
OR SECTION 602(b) OF TITLE VI OF DIVISION F OF PUBLIC LAW 111-8, RELATING
TO IRAQUI AND AFGHAN TRANSLATORS/INTERPRETERS OF THOSE WHO
WORKED FOR OR ON BEHALF OF THE UNITED STATES GOVERNMENT.
IF YOU SELECTED YES, YOU MUST ATTACH EVIDENCE OF YOUR STATUS AS A
REFUGEE, ASYLEE, OR SPECIAL IMMIGRANT VISA HOLDER. FAILURE TO DO SO
MAY RESULT IN APPLICATION REVIEW DELAYS.
ACCEPTABLE DOCUMENTATION
•
FORM I-94, ARRIVAL/DEPARTURE RECORD, WITH AN ADMISSION CLASS CODE
SUCH AS “RE” (REFUGEE) OR “AY” (ASYLEE) OR OTHER INFORMATION
DESIGNATING THE PERSON A REFUEE OR ASYLEE.
•
SPECIAL IMMIGRANT VISA THAT INCLUDES THE “SI” OR “SQ”
•
PERMANENT RESIDENT CARD (FORM I-551), COMMONLY KNOWN AS A “GREEN
CARD,” WITH A CATEGORY DESIGNATION INDICATING THAT THE PERSON WAS
ADMITTED AS A REFUGEE OR ASYLEE.
•
AN ORDER FROM A COURT OF COMPETENT JURISDICTION OR OTHER
DOCUMENTARY EVIDENCE THAT PROVIDES REASONABLE ASSURANCE THAT
THE APPLICANT QUALIFIES FOR EXPEDITED LICENSURE.
YES
NO
11.
ARE YOU REQUESTING EXPEDITING OF THIS APPLICATION FOR SPOUSES OR
DOMESTIC PARTNERS OF AN ACTIVE DUTY MEMBER OF THE U.S. ARMED
FORCES?
MILITARY SPOUSE OR DOMESTIC PARTNER REQUIREMENTS
NOTE: IF YOU MEET MILITARY SPOUSE OR DOMESTIC PARTNER REQUIREMENTS
PLEASE SCAN AND ATTACH THE FOLLOWING DOCUMENTATION ON THE
ATTACHMENTS PAGE OF THIS APPLICATION (YOU MAY BE ASKED TO SUBMIT
ORIGINAL DOCUMENTATION):
•
CERTIFICATE OF MARRIAGE OR DOMESTIC PARTNERSHIP OR OTHER LEGAL
UNION WITH AN ACTIVE DUTY MEMBER OF THE ARMED FORCES OF THE UNITED
STATES WHO IS ASSIGNED TO A DUTY STATION IN THIS STATE UNDER OFFICIAL
ACTIVE DUTY MILITARY ORDERS.
•
VERIFICATION OF CURRENT LICENSE IN ANOTHER STATE, DISTRICT, OR
TERRITORY OF THE UNITED STATES IN THE PROFESSION OF VOCATION FOR
WHICH YOU ARE SEEKING LICENSURE.
YES
NO
12. ARE YOU REQUESTING EXPEDITING OF THIS APPLICATION FOR HONORABLY
DISCHARGED MEMBERS OF THE U.S. ARMED FORCES?
MILITARY HONORABLE DISCHARGE REQUIREMENTS
NOTE: IF YOU MEET THE U.S. ARMED FORCES EXPEDITE REQUIREMENT, PLEASE
SCAN AND ATTACH A COPY OF THE FOLLOWING DOCUMENTATION ON THE
ATTACHMENTS PAGE OF THIS APPLICATION:
•
DD214 OR OTHER SUPPORTING DOCUMENTATION.
YES
NO
13.
PURSUANT TO BUSINESS AND PROFESSIONS CODE 1647.22(B), A DENTIST WHO ADMINISTERS, OR WHO
ORDERS THE ADMINISTRATION OF ORAL CONSCIOUS SEDATION FOR AN ADULT PATIENT SHALL BE
PHYSICALLY PRESENT IN THE TREATMENT FACILITY WHILE THE PATIENT IS SEDATED AND SHALL BE
PRESENT UNTIL DISCHARGE OF THE PATIENT FROM THE FACILITY.
PROVIDE THE ADDRESSES OF ALL LOCATIONS OF PRACTICE WHERE YOU ORDER OR
ADMINISTER ORAL CONSCIOUS SEDATIONTO ADULT PATIENTS.
14.
CERTIFICATION - I CERTIFY UNDER THE PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF
CALIFORNIA THAT THE FOREGOING IS TRUE AND CORRECT AND I HEREBY REQUEST A CERTIFICATE TO
ADMINISTER OR ORDER THE ADMINISTRATION OF ADULT ORAL CONSCIOUS SEDATION IN MY OFFICE
SETTING(S) AS SPECIFIED BY THE DENTAL PRACTICE ACT. I UNDERSTAND THAT FALSIFICATION OR
MISREPRESENTATION OF ANY ITEM OR RESPONSE ON THIS APPLICATION OR ANY ATTACHMENT IS
GROUNDS FOR DENYING MY APPLICATION FOR A CERTIFICATE.
SIGNATURE OF APPLICANT
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. 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.
YOUR NAME AND ADDRESS LISTED ON THIS APPLICATION WILL BE DISCLOSED TO THE PUBLIC UPON
REQUEST IF AND WHEN YOU BECOME LICENSED
.
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APPLICATION FOR ADULT ORAL CONSCIOUS SEDATION CERTIFICATE (California)

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Completed 8 February 2021

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