(1) The application and examination(s) fees as set by Section 1021;

(2) Satisfactory evidence that the applicant has met all applicable requirements in Sections 1628 and 1632 of the Code;

(3) The applicant shall furnish two classifiable sets of fingerprints or submit a Live Scan inquiry to establish the identity of the applicant and to permit the Board to conduct a criminal history record check. The applicant shall pay any costs for furnishing the fingerprints and conducting the criminal history record check;

(4) Where applicable, a record of any previous dental practice and certification of license status in each state or jurisdiction in which licensure as a dentist has been attained;

(5) Applicant's name, social security number, address of residency, mailing address if different from address of residency, date of birth, telephone number, and gender of applicant;

(6) Information as to whether the applicant has ever taken the California Law and Ethics written examination;

(7) Any request for accommodation pursuant to the Americans with Disabilities Act;

(8) A 2-inch by 2-inch passport style photograph of the applicant, submitted with the “Application for Licensure to Practice Dentistry (WREB)” Form 33A-22W (Revised 11/06), or “Application for Determination of Licensure Eligibility (Portfolio)” Form 33A-22P (New 11/2014);

(9) Information regarding applicant's education including dental education and postgraduate study, if applicable;

(10) Certification from the dean of the qualifying dental school attended by the applicant to certify the date the applicant graduated;

(11) Information regarding whether the applicant has any pending or had in the past any charges filed against a dental license or other healing arts license;

(12) Information regarding any prior disciplinary action(s) taken against the applicant regarding any dental license or other healing arts license held by the applicant including actions by the United States Military, United States Public Health Service or other federal government 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 license. If an applicant answers “yes”, he or she shall provide the date of the effective date of disciplinary action, the state where the discipline occurred, the date(s), charges convicted of, disposition and any other information requested by the board;

(13) Information as to whether the applicant is currently the subject of any pending investigation by any governmental entity. If the applicant answers “yes,” he or she shall provide any additional information requested by the board;

(14) Information regarding any instances in which the applicant was denied a dental license, denied permission to practice dentistry, or denied permission to take a dental board examination. If the applicant answers “yes”, he or she shall provide the state or country where the denial took place, the date of the denial, the reason for denial, and any other information requested by the board;

(15) Information as to whether the applicant has ever surrendered a license to practice dentistry in another state or country. If the applicant answers “yes,” additional information shall be provided including state or country of surrender, date of surrender, reason for surrender, and any other information requested by the board;

(16) Information as to whether the applicant is in default on a United States Department of Health and Human Services education loan pursuant to Section 685 of the Code; and

(17) A certification, under the penalty of perjury, by the applicant that the information on the application is true and correct.

(1) The earliest date upon which a candidate may submit their portfolio for review by the board shall be within 90 days of graduation. The latest date upon which a candidate may submit their portfolio for review by the board shall be no more than 90 days after graduation.

(2) The candidate shall arrange with the dean of his or her dental school for the school to submit the completed portfolio materials to the Board.

(3) The Board shall review the submitted portfolio materials to determine if it is complete and the candidate has met the requirements for Licensure by Portfolio Examination.