Fillable APPLICATION FOR REGISTERED DENTAL ASSISTANT (RDA) (California)

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APPLICATION FOR REGISTERED DENTAL ASSISTANT (RDA) (California)

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Country of origin: US
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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
APPLICATION FOR REGISTERED DENTAL ASSISTANT (RDA) EXAMINATION AND LICENSURE
See Instructions for completing and filing this application. Please read carefully and answer each question fully. Falsification or
misrepresentation of any item or response on this application or any attachment hereto is sufficient basis for denying or
revoking a license.
Non-Refundable Fees For Office Use Only For Office Use Only
Date Received
Application: $120 Rec #
A written examination fee will be Fee Paid:
required to be paid directly to PSI at a
later date. Date
Cashiered:
Entity #
File # _
(Please print or type)
1. SSN/FEIN/ITIN #: 2. Birth Date (MM/DD/YYYY)
3. Legal Name: Last First Middle
4. List any other names used:
5. Mailing Address (The address you enter is public information and will be placed on the Internet pursuant to B & P Code 27):
6. E-Mail Address:
7. Home Telephone (Include area code): 8. Work Telephone (Include area code):
9. Have you been licensed to practice dental assisting, orthodontic assisting, dental sedation
assisting, dental hygiene, dentistry or any other health care profession in California, any other
Yes No
state, or foreign country?
Type of Practice: License Number: State/Country:
10. Have you ever had any disciplinary action taken or charges filed against your dental license or other
health related license by a government agency?
“License” includes permits, registrations, and certificates. Include any disciplinary actions taken by
this agency, any other state agency, any U.S. territory, the U.S. Military, U.S. Public Health Service
Yes
or other U.S. federal governmental entity. Disciplinary action includes, but is not limited to,
suspension, revocation, probation, confidential discipline, consent order, letter of reprimand or
warning, or any other restriction or action taken against a dental or health-related license that
No
was issued to you.
If the answer is “yes”, provide the section of law violated the nature of the violation, the location
and date of the violation, and the penalty or disposition on a separate sheet and include with this
application.
11. Have you ever had a dental or other health-related license denied in this state or any other state?
Yes
If “yes”, provide a detailed explanation of circumstances surrounding the denial, including the
date of the denial, type of application, and the basis for the denial. Include a copy of any
No
document(s) you received from the agency denying your application(s).
12. Have you ever surrendered a dental license, either voluntarily or otherwise?
Yes
If “yes”, provide a detailed explanation of the circumstances, including the date of the surrender,
No
the reason for the surrender and a copy of all documents relating to the surrender.
13. EVIDENCE OF COMPLETION OF REQUIRED CERTIFICATIONS
Candidates for the RDA examination must submit evidence of having completed the following Board-
approved courses:
(check all requirements completed) Evidence of completion shall be attached to the
application.
Radiation Safety Coronal Polishing Infection Control CA Dental Practice Basic Life Support Live Scan
(32-hour course) (16-hour course) (8-hour course) Act (2hour course) (AHA/ARC) Form
14. EXECUTION OF APPLICATION
I am the applicant for examination for licensure referred to above. I have read the questions in the foregoing
application and have answered them truthfully, fully and completely.
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signed in on t he of , 20_____.
(City/State) (Day) (Month) (Yr)
(Signature of Applicant)
2
INFORMATION COLLECTION AND ACCESS
The information requested herein is mandatory and is maintained by the Executive Officer, Dental Board of
California, 2005 Evergreen Street, Suite 1550, Sacramento, CA 95815, (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 for licensure pursuant to Business and professions Code sections 1752.1 and 1752.3, issue and
renew licenses, and enforce licensing standards set by law and regulation. 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. The official responsible for information
maintenance is the Executive Officer (916) 263-2300, 2005 Evergreen Street, Suite 1550, Sacramento, California
95815. Each individual has the right to review the personal information maintained by the agency unless the
records are exempt from disclosure. We make every effort to protect the personal information you provide us.
However, in accordance with Section 27 of the Business and Professions Code, your name and mailing address
listed on this application will be disclosed to the public upon request or through license verification on the Board’s
web site, if and when you become licensed. Other information you provide may be disclosed in the following
circumstances: (1) in response to a Public Records Act request (Government Code section 6250 and following), as
allowed by the Information Practices Act (Civil Code section 1798 and following); (2) to another government
agency as required by state of federal law; or (3) in response to a court or administrative order, subpoena or
search warrant.
3
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APPLICATION FOR REGISTERED DENTAL ASSISTANT (RDA) (California)

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Completed 31 July 2020

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