2001 Capitol Avenue, Room 104 Cheyenne, WY 82002 DENTAL REINSTATEMENT INSTRUCTIONS To obtain reinstatement, you are required to meet the requirements in Chapter 3, Section 13 of the Board’s Rules and Regulations. APPLICATION The Board requires receipt of the complete, original signed application; therefore, faxed and incomplete applications are unacceptable. The application fee of $750.00 (non-refundable) in the form of a cashier’s check or money order, made payable to the State of Wyoming must be mailed with the application. PROOF OF LAWFUL PRESENCE Required by Federal law, the Board must receive proof of lawful presence from every applicant. Most applicants find it easiest to provide a copy of a social security card, a copy of a legal birth certificate, or a copy of a US Passport. The Board only needs a copy of one of these. If you cannot provide any of the previously mentioned documents, please consult List A&B of this packet for other acceptable documents. CPR REQUIREMENT Basic Life Support (CPR) is required for licensure and renewal. The course needs to be a hands-on course sponsored by one of the following organizations: American Heart Association, American Red Cross, or a Board approved course. Submit a copy of your current cards along with your application to the Board. COMPETENCY The Board requires evidence of compliance with the requirements of the previous Board order, evidence of the ability to safely and competently practice, and evidence demonstrating just cause for reinstatement.

LIST A ACCEPTABLE DOCUMENTS TO ESTABLISH U.S. CITIZENSHIP A person who is a citizen of the United States as evidenced by one of the following: 1. 2. 3.

4. 5. 6. 7. 8. 9.

A copy of a birth certificate issued in or by a city, county, state, or other governmental entity within the United States or its outlying possessions. A U.S. Certificate of Birth Abroad (FS-545, DS-135) or a Report of Birth Abroad of a U.S. Citizen (FS-240). A birth certificate or passport issued from: A. Puerto Rico, on or after January 13, 1941; B. Guam, on or after April 10, 1898; C. U.S. Virgin Islands, on or after February 25, 1927; D. Northern Mariana Islands, after November 4, 1986; E. American Samoa; F. Swain’s Island; or G. District of Columbia. A U.S. passport (expired or unexpired). Certificate of Naturalization (N-550, N-57, N-578). Certificate of Citizenship (N-560, N-561, N-645). U.S. Citizen Identification Card (I-179, I-197). An individual Fee Register Receipt (Form G-711) that shows that the person has filed an application for a New Naturalization or Citizenship Paper (Form N565). Any other document which establishes a U.S. place of birth or indicates U.S. citizenship.

LIST B ACCEPTABLE DOCUMENTS TO ESTABLISH ALIEN STATUS An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA) must submit supporting documentation to establish legal presence under one of the following categories: 1.

2.

3.

4. 5.

6.

7.

8. 9.

An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). Evidence includes: Χ INS Form I-551 (Alien Registration Receipt Card commonly known as a Αgreen card≅); or Χ Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94. An alien who is granted asylum under Section 208 of the INA. Evidence includes: Χ INS Form I-94 annotated with stamp showing grant of asylum under Section 208 of the INA; Χ INS Form I-688B (Employment Authorization Card) annotated Α274a.12(a)(5)≅; Χ INS Form I-766 (Employment Authorization Document) annotated ΑA5"; Χ Grant Letter from the Asylum Office of INS; or Χ Order of an immigration judge granting asylum. A refugee admitted to the United States under Section 207 of the INA. Evidence includes: Χ INS Form I-94 annotated with stamp showing admission under Section 207 of the INA; Χ INS Form I-688B (Employment Authorization Card) annotated Α274a.12(a)(3)≅; Χ INS Form I-766 (Employment Authorization Document) annotated ΑA3"; or Χ INS Form I-571 (Refugee Travel Document). An alien paroled into the United States for at least one year under Section 212(d)(5) of the INA. Evidence includes: Χ INS Form I-94 with stamp showing admission for at least one year under Section 212(d)(5) of the INA. An alien whose deportation is being withheld under Section 243(h) of the INA (as in effect immediately prior to September 30, 1996) or Section 241(b)(3) of such Act (as amended by Section 305(a) of Division C of Public Law 104-208). Evidence includes: Χ INS Form I-668B (Employment Authorization Card) annotated Α274a.12(a)(10)≅; Χ INS Form I-766 (Employment Authorization Document) annotated ΑA10"; or Χ Order from an immigration judge showing deportation withheld under Section 243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under Section 241(b)(3) of the INA. An alien who is granted conditional entry under Section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidence includes: Χ INS Form I-94 with stamp showing admission under Section 203(a)(7) of the INA; Χ INS Form I-688B (Employment Authorization Card) annotated Α274a.12(a)(3); or Χ INS Form I-766 (Employment Authorization Document) annotated ΑA3". An alien who is a Cuban or Haitian entrant (as defined in Section 501(e) of the Refugee Education Assistance Act of 1980). Evidence includes: Χ INS Form I-551 (Alien Registration Receipt Card, commonly known as a Αgreen card≅) with the code CU6, CU7, or CH6; Χ Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with code CU6 or CU7; or Χ INS Form I-94 with stamp showing parole as ΑCuban/Haitian Entrant≅ under Section 212(d)(5) of the INA. An alien paroled into the United States for less than one year under Section 212(d)(5) of the INA. Evidence includes: Χ INS Form I-94 showing this status. An alien who has been declared a battered alien. Evidence includes: Χ INS petition and supporting documentation. The preceding lists (A and B) contain the most common documents which can be used to establish U.S. Citizenship or legal alien status.

2001 Capitol Avenue, Room 104 Cheyenne, WY 82002 APPLICATION FOR DENTIST REINSTATEMENT This form, all relevant documentation, and the $750 fee must be received by the Board office in order to be considered for reinstatement. Please type or print neatly.

1. Applicant Information Last Name

First Name

Social Security #

Date of Birth

Middle Initial

Citizenship 

U.S.

Previous Names Used

WY License # 

DEA #

Other

2. Home Mailing Address Home Mailing Address

City

Home Phone

Cell Phone

State

Zip

State

Zip

State

Zip

3. Business Mailing Address Wyoming Business Mailing Address

City

Business Phone

Business Fax

Other Business Mailing Address

City

Business Phone

Business Fax

Type of Practice

4. Correspondence from Board Office I prefer to receive mail at my:  Home  Wyoming Business  Other Business Issues with your application and general correspondence will be sent to you via email. My preferred email address is:

5. Basic Life Support I have Basic Life Support (CPR) certification. Yes _______

No ________

6. Practice History The last year I actively practiced dentistry was: I have submitted documentation of:  Evidence of complying with the requirements of a previous Board order,  Evidence of my ability to safely and competently practice,  Evidence demonstrating just cause for reinstatement. If you mark yes to any of the below questions, you must attach a detailed explanation. Provide copies of documentation if applicable.

a. Have you ever had any application for licensure or certification refused, dismissed, denied, or withdrawn by any professional licensing authority?

 Yes  No

b. Have you ever allowed any professional license to lapse in lieu of disciplinary action, or had a limited, conditioned, restricted, or probationary license issued by any licensing authority?

 Yes  No

c. Have you had a professional license revoked, voluntarily surrendered, suspended, reprimanded, censured, conditioned, restricted, or otherwise disciplined?

 Yes  No

d. Have you ever had a registration issued by a controlled substance authority revoked, voluntarily surrendered, suspended, reprimanded, censured, conditioned, restricted, or otherwise disciplined. e. Have you had an application for registration refused, dismissed, denied, or withdrawn by a controlled substance authority? f.

Have any unresolved or pending complaints ever been filed against you with any licensing agency or association?

g. Is there any disciplinary action pending against you by any licensing authority, the USDA, Drug Enforcement Agency, or any state drug enforcement authority? If YES, where and when?

 Yes  No  Yes  No  Yes  No

 Yes  No

h. Have you ever been charged or convicted (including a nolo contendere plea or guilty plea) of a misdemeanor, felony, or other criminal offense (other than minor traffic violations) in any state or federal court? If YES, in addition to the affidavit, attach a certified copy of the court records regarding your conviction, the nature of the offense date of discharge, if applicable, as well as a statement from the probation or parole officer. i. Are you currently addicted to or abusing any chemical substance including alcohol (excluding tobacco and caffeine) that would impair your ability to practice? j. Do you currently have or have you been previously diagnosed with any condition or impairment (including but not limited to, substance abuse, alcohol abuse, or a mental, emotional or nervous disorder, or condition) that in any way affects your ability to practice dentistry in a competent, ethical, and professional manner? k. Have you been named as a defendant to a civil suit related to your practice or profession (i.e. malpractice, Medical Review Panel)?

 Yes  No

 Yes  No

 Yes  No

 Yes  No

7. Warning, Agreement, Affidavit, and Signature By signing this application:

I understand that making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than two (2) years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 6-5-303.) I do hereby state that I have read, understand, and agree to abide by the rules and regulations promulgated by the Board of Dental Examiners, and W.S. § 33-15-101 through 133. I also agree to adhere to the codes of ethics applicable to my profession and this application. I verify that I am the person making the foregoing statements and that they are made in good faith and are true in every respect.

SIGNATURE OF APPLICANT

DATE