Section 1042.2 - Application; Process(a) A dentist who desires to participate in the program shall submit an application to the Board on the Dental Loan Repayment Program Application (rev. 1/05), which is incorporated by reference, and which includes all of the following: (1) Applicant's name, California dental license number, address, telephone numbers, social security number, date of birth, e-mail address (if available), permit number of any permits issued by the Board, and date of issuance of first dental license and issuing body.(2) Which of the criteria listed in Section 1972(b)(1) of the code or in section 1042.1 the applicant meets and why, including dates of and institutions where postgraduate training occurred.(3) The name of each lender from which the applicant obtained an educational loan, together with the most current loan statement(s) that contains the lender's name(s) and mailing address(es), the applicant's name and loan account number(s), the outstanding balance(s) of the loan, the purpose for which the loan(s) was (were) given, and the date on which the loan statement(s) was (were) issued.(4) Whether the applicant has ever been in default or had a judgment lien against the applicant for any debt, and an explanation for each default or judgment lien.(5) Whether the applicant is willing to sign, or has signed, a written agreement with the practice setting(s) committing to three years of full-time service in a dentally underserved area.(6) The name and address of each practice location at which services are to be provided under the program.(7) A statement authorizing release to the Board of information enumerated in the application and any attachments thereto.(8) A certification under penalty of perjury, signed and dated by the practice setting's administrative officer, whose name is printed below his/her signature, that the facility has entered into an agreement with the applicant for a minimum of three years; that the applicant can speak a Medi-Cal threshold language effectively in order to provide service; that it will pay the applicant a prevailing wage and not offset any loan repayments by the program against the applicant's salary; and that it is a "practice setting" as defined in Section 1971(f) of the code.(9) A certification under penalty of perjury as to the contents of the application and any attachments, signed and dated by the applicant.(b) Application filing periods will be dependent upon available funding and the number of openings in the program. Every application filing period shall be posted on the board's website and shall close not earlier than 30 days after the date on which openings are first posted. Section 1042.3(a) notwithstanding, an application that is either not complete or not received by the final filing date shall not be considered, and shall be returned to the applicant.Cal. Code Regs. Tit. 16, § 1042.2
1. New section filed 1-6-2005; operative 2-5-2005 (Register 2005, No. 1). Note: Authority cited: Sections 1614 and 1972, Business and Professions Code. Reference: Sections 1971- 1972, Business and Professions Code.
1. New section filed 1-6-2005; operative 2-5-2005 (Register 2005, No. 1).