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Branch License Request Form - Dentists

New Jersey State Board of Dentistry
124 Halsey Street, 6th Floor
P.O. Box 45005, Newark, New Jersey 07101
Telephone: (973) 504-6405
Fax: (973) 273-8075

The Statutes governing the practice of dentistry require that a licensee display a current registration certificate in a conspicuous place in plain view of patients. Likewise, a branch office certificate is required to be issued for every location in which a licensed dentist practices. The branch office is $90 for a two year (biennial) period. If you are submitting payment in the second half of a biennial period (for example: after October 31 of an even numbered year), the fee is $45.00. Checks should be made payable to the "New Jersey Board of Dentistry." Return this application to the address listed above. Please print or type clearly:

Name of Applicant
____________________________
Social Security Number*
____________________________
Check one:
Dentist _____
Business Name/Owner of Practice
____________________________
Street Address
 
____________________________

____________________________
City/State/Zip
____________________________
Telephone Number
____________________________

*NOTE: In order to process the application, you are now required to provide your social security number. This number is not currently held by the Board office in any form. Pursuant to N.J.S.A. 2A-17-56(e) of the New Jersey child support enforcement law and N.J.S.A. 54:50-25 of the New Jersey taxation law, the Board or licensing agency to which this form is submitted is required to obtain your social security number and/or your federal taxpayer identification number, and where neither is possessed, the reason for not having such a number. The Board is further obligated to provide these identifying numbers to the director of the Division of Taxation and the Probation Division or other agency responsible for child support enforcement.

You are hereby notified under the federal Privacy Act (5 U.S.C., Section 552a (note b), the Board or licensing Agency to which this form is submitted is requesting the voluntary disclosure of your social security number. If you give your consent to the use of your social security number, it may be used: to verify the identity of an applicant, to aid in the collection of financial obligations due and owing the Board or any other state agency, and to aid in the disclosure to state or federal law enforcement and licensing officials and agencies of information obtained in investigations pertaining to licensure and disciplinary proceedings.

Please return this form to the address noted above, and your application will be immediately processed.

I, (print name)____________________________, Consent_____, Do Not Consent_____ to the use of my social security number for any of the purposes set forth in the notice under the federal Privacy Act noted above. I understand that my consent is voluntary and that if I do not consent, no adverse action or inference will be taken or drawn.

_______________________ Date

____________________________ Signature

   
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