APPLICATION PACKET

 

WHAT IS INCLUDED IN THE APPLICATION PACKET THAT PBIS CREATES AND SUBMITS TO THE DENTAL BOARD(S)?


**PLEASE BE ADVISED THAT EACH STATE HAS DIFFERENT REQUIREMENTS FOR LICENSURE**
*WE MAY REQUEST ADDITIONAL INFORMATION FROM YOU IN ADDITION TO THE LIST BELOW*


The PBIS Application is a 2-Part Process:
    1. Online Application (Demographics, Education, Exams, Licenses, Employment, References, Questionnaire, Malpractice Insurance, No Time Gaps, Etc.)
    2. Notarized Back-Up Documents (Printed from the Online Application - Forms)
    • Affidavit – (Requires Wet Signature)
    • Release Form – (Requires Wet Signature)
    • Designated State Form (Which State You Are Applying To)
  • You Can Submit Either Part in Any Order
  • *NOTE - We Cannot START Your Application Until BOTH Parts Have Been Submitted to PBIS
  • Payment is Made Online Only by Credit/Debit Card Once the Application is Complete
  • PBIS Online Application Completed by the Applicant
  • Notarized Affidavit (Back-Up Document)
  • Notarized Release of Records Form (Back-Up Document)
  • Designated Recipient Form (Back-Up Document)
  • Any State Specific Required Forms
  • Passport/Birth Certificate Copies
  • CPR Certification Copies
  • Dental Related Diplomas/Program Completion Certificates Copies
  • Continuing Education Certificates Copies (If Applicable)
  • Name Change Document Copies (If Applicable)
  • Criminal/Civil/County Background Check Results
  • Education Verification(s) – Applicant May Need to Obtain – School Requirement
  • Specialty Board Verification(s) (If Applicable)
  • Examination Verification(s)
  • Licenses and Disciplinary Actions (If Applicable)
  • Malpractice Insurance Coverage (If Applicable)
  • Notarized Proof of Clinical Practice References (If Applicable)
  • Moral References (If Applicable)
  • Character References (If Applicable)
  • Information Summary
  • Omission and Discrepancy Report

*Please Be Advised that PBIS Maintains Complete Confidentiality of Reports and All Documentation. This Application Packet Can Only be Released to the Designated Licensing Board and Cannot Legally Be Released to the Applicant. The Applications are Held for 2 Years from the Initial Date of Receipt.

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