Submit your completed application form along with the required fee to the Dental Board of California at 2005 Evergreen St., Suite 1550, Sacramento, CA 95815. You may also choose to fax your application to (916) 263-2140 or submit online through the California Dental Board website. To ensure your application is processed without issues, please double-check that all sections are completed and the necessary documentation is included.

There are no specific dates listed for submission, but timely completion is encouraged to meet licensure requirements. For updates on examination schedules and application deadlines, applicants should refer to the Dental Board of California's official calendar for 2024 and 2025.

The purpose of this form is to provide a structured application for individuals aspiring to obtain licensure as Registered Dental Assistants in California. It guides applicants through the necessary steps and documentation needed to demonstrate their qualifications. Ensuring that all required fields are completed accurately is crucial for a smooth application process.

• 1. SSN/ITIN: Social Security Number or Individual Taxpayer Identification Number.
• 2. Birth Date: Applicant's date of birth in MM/DD/YYYY format.
• 3. Legal Name: Full legal name as it appears on identification documents.
• 4. Other Names Used: Any prior names the applicant might have used.
• 5. Mailing Address: Address to which communications will be sent.
• 6. E-Mail Address: Email address for correspondence.
• 7. Home Telephone: Primary contact number including area code.
• 8. Work Telephone: Alternative contact number including area code.
• 9. Previous Licensure: Information regarding any previous licenses held by the applicant.
• 10. Initial Application Asylum Question: Questions related to asylum status.

Failure to submit this application means you won't be eligible to take the Registered Dental Assistant Examination. It may result in delays in your licensure process as you must reapply. Ensure that all required fields and documentation are included to avoid setbacks.

• Missing Documentation: Not providing required documents can lead to application rejection.
• Incomplete Information: Leaving fields blank or providing inaccurate data can delay application processing.
• Failure to Pay Fees: Non-payment of the application fee will result in ineligibility.

• 1. Applying for New Licensure: Use this form to obtain your first licensure as an RDA.
• 2. Reinstating Licensure: For individuals who have previously held a dental license and are reapplying.
• 3. International Applicants: Individuals trained outside the United States seeking to practice in California.