Lic # Issued App # MINNESOTA BOARD OF DENTISTRY 2829 University Avenue SE, Suite 450 Minneapolis, Mi-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your Lic # and App # at the top of the form. Ensure that all information is accurate to avoid any delays.
3. In the Background section, provide your full name, home address, telephone number, email address (optional), today's date, sex, birth date, and social security number. Make sure to type or print clearly.
4. Complete the Dental Assisting Education section by entering the name of your dental assisting school and attaching a notarized copy of your diploma or certificate.
5. Fill out the Location of Guest Registration Practice section with details about the public health clinic where you will be practicing. Include the clinic's name, address, and supervisor’s name.
6. Answer all yes/no questions regarding your agreement to treat indigent patients and understanding of registration responsibilities. Be honest as inaccuracies can lead to application denial.
7. Attach any required documents such as letters from clinics and affidavits as specified in the instructions before submitting your application.

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