Verification of Licensure Request Form

ASBDE License Verification Request Form

Complete this form and submit if you want the Arkansas State Board of Dental Examiners to provide an official verification of your license or permit.

My Information

Name(Required)

First Last Suffix

I am requesting verification of(Required)

Dental license

Hygiene License

Dental Assisting Permit

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

License/permit number

Email(Required)

Phone(Required)

License Verification Recipient Information

How do you want the verification to be sent (check one)?(Required)

Mail

Name/organization to send verification to:(Required)

Recipient's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Recipient's email address

The Arkansas State Board of Dental Examiners will provide official verification of your license/permit. We will not provide specific examination information (i.e scores and test results). If you choose the “mail” option, your verification will be sent via regular mail only.

Boards & Commissions

ASBDE License Verification Request Form

My Information

License Verification Recipient Information

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Contact ADH

Your Arkansas.gov

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