Application Forms

The following forms may be printed and attached with your application for license, permit, registration or qualification. If the application will be completed online, you may scan/photograph and attach the completed forms prior to submitting the application. If you have already submitted an application, you may email or fax the completed forms.

Please note: The original copy of the Certification of Education should be forwarded to the Board office to complete your application.

National Practitioner Data Bank (NPDB)

Applicants for a dental license, dental hygiene license or faculty permit must submit the results of a self-query of the National Practitioner Data Bank. To submit a request to the NPDB for a self query, please visit the NPDB's website. Upon receipt of the results, please email or fax a copy of the results to the Board office. You are not required to forward an original copy of the results to the Board.

Dental Assistants
Dental Assistant Trainee	Dental Assistant Trainee Certification (Statement of Applicant/Statement of Employer)
RDA/QDA Application Forms	Affidavit of Employment ^{Required if training was completed as a dental assistant trainee.} Certification of Education ^{For graduates of an ADA-accredited dental assisting program.}
XDA/QDA Radiography Qualification	Certification of Dental Radiography Training ^{For Iowa nurses applying for an XDA, or an RDA applying for a QDA.}
Dental Hygienists
RDH License Application Forms	Authorization for Release Certification of Education Certification of License ^{Request written certification of all licenses that have been issued to you.}
Local Anesthesia Application Forms	Certification of Local Anesthesia Training Certification of Local Anesthesia Administration
Dentists
DDS License Application Forms	Authorization for Release Certification of Education Certification of License ^{Request written certification of all licenses that have been issued to you.}
Moderate Sedation or General Anesthesia Application Forms	Certification of Moderate Sedation Training Verification of Postgraduate Residency Program (General Anesthesia)
Faculty/Residents
The following forms need to be submitted with an application for faculty permit or resident license. The forms must be completed by the University of Iowa College of Dentistry or other ADA-accredited program in Iowa where the applicant is employed as a faculty member or enrolled as a resident.
Faculty Certification	Faculty Certification
Resident Certification	Resident Certification
Petition for Determination of Eligibility for Licensure or Registration
The following form may be used by potential applicants in cases where the applicant would like the Board or the Dental Hygiene Committee to review a criminal history for a determination as to whether the applicant would be eligible for licensure in Iowa. Petition for Eligibility of Licensure Registration

Please submit the completed forms to:

Iowa Dental Board
400 SW 8th St. Suite D
Des Moines, IA 50309
Email: IDB@iowa.gov
Fax: 515-281-7969

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Application Forms

National Practitioner Data Bank (NPDB)

Dental Assistants

Dental Hygienists

Dentists

Faculty/Residents

Petition for Determination of Eligibility for Licensure or Registration