The verification shall include all of the following:
I hereby attest that I meet all of the requirements for temporary licensure as set forth in Business and Professions Code Section 115.6(c)(1) through (5), including that I have not committed an act in any jurisdiction that would have constituted grounds for denial, suspension, or revocation of the license under the Business and Professions Code at the time the act was committed and I am aware that a violation of this paragraph may be grounds for the denial or revocation of a temporary license issued by the Board. I also attest to the fact that I have not been disciplined by a licensing entity in another jurisdiction and am not the subject of an unresolved complaint, review procedure, or disciplinary proceeding conducted by a licensing entity in another jurisdiction. I also understand that I will be required to furnish a full set of fingerprints for purposes of conducting a criminal background check. I further attest that the information submitted in this application is accurate, to the best of my knowledge.
Notice: Falsification or misrepresentation of any item or response on this application or any attachment hereto is grounds for denying the application. In addition, any temporary license issued after the application is processed will be immediately terminated upon a finding that the license holder provided substantively inaccurate information that would affect the person's eligibility for temporary licensure (Bus. & Prof. Code, § 115.6).
DENTAL BOARD OF CALIFORNIA
ATTENTION: LICENSING AND EXAMINATION UNIT
2005 EVERGREEN ST., SUITE 1550
SACRAMENTO, CA 95815
Cal. Code Regs. Tit. 16, § 1006
Note: Authority cited: Sections 115.6 and 1614, Business and Professions Code. Reference: Sections 480, 115.6, 1611, 1632, 1638, 1638.1 and 1749.1, Business and Professions Code.