R4-11-901. Application for Restricted Permit

A. An applicant for a restricted permit shall provide the following information and documentation on a form provided by the Board: 1. A sworn statement of the applicant’s qualifications for a restricted permit; 2. A photograph of the applicant that is no more than six months old; 3. A letter from any other jurisdiction in which an applicant is licensed or certified verifying that the applicant is licensed or certified in that jurisdiction, sent directly from that jurisdiction to the Board; 4. If the applicant is in the military or employed by the United States government, a letter from the applicant’s commanding officer or supervisor verifying the applicant is licensed or certified by the military or United States government; 5. A copy of the applicant’s current cardiopulmonary resuscitation certification that meets the requirements of R4- 11-301(A)(6); and 6. A copy of the applicant’s pending contract with a Charitable Dental Clinic or Organization offering dental or dental hygiene services. B. The Board may request that an applicant provide a copy of a certified document that indicates the reason for a name change if the applicant’s application contains different names.