Central Regional Dental Testing Service

50 Years of Dental and Dental Hygiene Testing Excellence!

Exam Application

I. Personal Information

Current Mailing Address

Candidate Photo
  1. The photo must be recent, and of passport quality.
  2. All photos will be reviewed by CRDTS and may be rejected if they are not found be acceptable for identification purposes. If determined to be unacceptable you will be notified by email and asked to upload a replacement photo.
  3. Photos must be in one of the following formats: JPG/JPEG, GIF, or PNG
  4. Photos must be square and have a minimal resolution of 200x200 and max resolution of 500x500
  5. Photo may be black & white OR color
  6. (click image to edit)
Exam Type
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II. Certification
I am a Junior Student of Record at an accredited dental school participating in the CRDTS Curriculum Integrated Format dental examination (Must furnish an original copy of the Letter of Certification for the Integrated Format Examination - Junior Student of Record).
I am a Senior Student of Record at an accredited dental school participating in the CRDTS Curriculum Integrated Format dental examination. (Must furnish an original copy of the Letter of Certification for the Integrated Format Examination - Senior Student of Record).
I am a Resident or Graduate Student of Record at a dental school participating in the CRDTS Curriculum Integrated Format dental examination and have graduated from a program accredited by the ADA Commission on Dental accreditation OR enrolled in an accredited program that leads to a DDS/DMD. (Must furnish an original copy of the Letter of Certification for the Integrated Format Examination - Resident or Graduate Student of Record).
I hold a diploma from an accredited dental school. (Must furnish a notarized copy of the diploma by the deadline date for the exam).
I will have successfully completed a prescribed course of study in an accredited dental school within 90 days after the examination date. (Must furnish an original copy of the Letter of Certification for the Dental Traditional Format Examination).
I hold a diploma from a non-accredited dental school. (Must furnish verification from the State Dental board of a state that accepts the results of the CRDTS examination indicating that you are eligible for licensure in the state upon successful completion of the CRDTS examination. In addition, a copy of your diploma with an English Translation MUST be provided).
III. Insurance Application
  1. Please provide details for any "YES" answer. A Student Dental Board Coverage Application (see Candidate Forms) must be submitted.
  2. A. Have you ever been treated for alcoholism, narcotic addiction or mental illness? Yes No
  3. B. Have you ever been charged or convicted of a felony? Yes No
  4. C. Have you ever had any chronic illness or physical defect? Yes No
  5. D. Have any claims or suits ever been filed against you as a result of professional Service rendered? Yes No
  6. E. Has this form of insurance or other similar insurance ever been cancelled, refused or nonrenewed? Yes No
IV. School of Graduation
 
V. Examination Schedules
VI. Examination Dates
  1. Integrated Examinations - Open to Students of Record ONLY

  2.  
  3. Traditional and Retake Examinations (Parts II-V) - Open to ALL Candidates

VII. Previous Examination Information
VIII. Limitation of Liability Agreement
  1. 1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
  2. 2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
  3. 3. Auxiliary Personnel: Use of Assistants. Auxiliary personnel are not permitted to assist at chairside during the manikin examinations. Auxiliary personnel are permitted to assist at chairside during periodontal and restorative examinations. Dentists, dental hygienists and dental therapists(any graduate, licensed or unlicensed), final year dental, dental hygiene or dental therapy students may not act as chairside assistants during the restorative and periodontal examinations.
  4. 4. Limitation of Liability, Assumption of Risk, and Indemnity.
    1. A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
    2. B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.
  5. 5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.
IX. Candidate Signature
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II. Certification
III. School of Graduation
 
Administering Local Anesthesia
I am not a present graduate or attending a school within the CRDTS Region. I must submit a certificate, or letter from my school or course on official letterhead verifying that I have had the appropriate educational and clinical training to administer local anesthesia at the examination site.
IV. Retake Examination
V. Exam Type Preference
VI. Examination Dates
  1. Please select three choices in chronological order.
VII. Previous Examination Information
VIII. Limitation of Liability Agreement
  1. 1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
  2. 2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
  3. 3. Patients. As part of the examination, you must perform certain types of clinical procedures on patients. Patients must sign a "Treatment Consent Form" prior to any procedure.
  4. 4. Limitation of Liability, Assumption of Risk, and Indemnity.
    1. A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
    2. B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.
  5. 5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.
IX. Candidate Signature



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II. School of Graduation
 
III. Restorative Training Verification
IV. Retake Examination
V. Examination Dates
VI. Previous Examination Information
VII. Limitation of Liability Agreement
  1. 1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
  2. 2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
  3. 3. Patients. As part of the examination, you must perform certain types of clinical procedures on patients. Patients must sign a "Treatment Consent Form" prior to any procedure.
  4. 4. Limitation of Liability, Assumption of Risk, and Indemnity.
    1. A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
    2. B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.
  5. 5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.
VIII. Candidate Signature


Prev Page Complete
II. School of Graduation
 
Administering Local Anesthesia
I am not a present graduate or attending a school within the CRDTS Region. I must submit a certificate, or letter from my school or course on official letterhead verifying that I have had the appropriate educational and clinical training to administer local anesthesia at the examination site.
III. Dental Hygiene - Certification
IV. Restorative Auxiliary - Training Verification
Prev Page Next Page
V. Dental Hygiene - Retake Examination
V. Dental Hygiene - Exam Type Preference
VII. Dental Hygiene - Examination Dates
  1. Please select three choices in chronological order.
VIII. Dental Hygiene - Previous Examination Information
Prev Page Next Page
IX. Restorative Auxiliary - Retake Examination
X. Restorative Auxiliary - Examination Dates
XI. Restorative Auxiliary - Previous Examination Information
Prev Page Next Page
XII. Limitation of Liability Agreement
  1. 1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
  2. 2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
  3. 3. Patients. As part of the examination, you must perform certain types of clinical procedures on patients. Patients must sign a "Treatment Consent Form" prior to any procedure.
  4. 4. Limitation of Liability, Assumption of Risk, and Indemnity.
    1. A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
    2. B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.
  5. 5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.
XIII. Candidate Signature




Prev Page Complete
II. Certification
III. School of Graduation
 
IV. Retake Examination
V. Examination Dates
  1. Traditional and Retake Examinations (Parts II-V) - Open to ALL Candidates
VI. Previous Examination Information
VII. Limitation of Liability Agreement
  1. 1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
  2. 2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
  3. 3. Auxiliary Personnel: Use of Assistants. Auxiliary personnel are not permitted to assist at chairside during the manikin examinations. Auxiliary personnel are permitted to assist at chairside during periodontal and restorative examinations. Dentists, dental hygienists and dental therapists(any graduate, licensed or unlicensed), final year dental, dental hygiene or dental therapy students may not act as chairside assistants during the restorative and periodontal examinations.
  4. 4. Limitation of Liability, Assumption of Risk, and Indemnity.
    1. A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
    2. B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.
  5. 5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.
VIII. Candidate Signature
Prev Page Complete
II. School of Graduation
 
III. Anesthesia Training Verification

IV. Retake Examination
V. Examination Dates
  1. Please select three choices in chronological order.
VI. Previous Examination Information
VII. Limitation of Liability Agreement
  1. 1. CRDTS Examinations. Central Regional Dental Testing Service, Inc. ("CRDTS"), is a Kansas non-profit corporation, which develops and administers dental and dental hygiene examinations to qualified candidates for licensure as either dentists or dental hygienists.
  2. 2. No Affiliation with Schools. The CRDTS examinations are typically administered at dental and dental hygiene schools in the United States. Other than administering an examination at a School, CRDTS has no relationship or affiliation with any of the Schools.
  3. 3. Volunteer Patients and Dental Assistants. As part of the examination, you must perform certain types of clinical procedures on volunteer patients. Volunteer patients must sign a "Treatment Consent Form" prior to any procedure. Dental candidates are permitted to use their own dental assistant(s) during the examinations, and they are required to supply both the volunteer patient(s) and dental assistant(s), if any, at their own expense. Dentists and dental hygienists (licensed or unlicensed), third or fourth year dental students, final year dental hygiene students, dental technicians and expanded duty auxiliaries (if providing services normally done by a dentist) may not act as chairside assistants during any CRDTS examination.
  4. 4. Limitation of Liability, Assumption of Risk, and Indemnity.
    1. A. CRDTS (including its examiners) and the Schools cannot, and therefore, do not assume any responsibility or liability for the health or dental care of you, your assistant or your patient. If any exposure or other injury occurs during the course of an examination, neither CRDTS (including its examiners) nor the School assumes any duty or responsibility to you, your assistant or your patient for any health care service, including, but not limited to, serologic testing, counseling, or follow-up care. It is your responsibility to assure that any individual involved sees a licensed health care professional and initiates appropriate treatment and follow-up care.
    2. B. You hereby expressly agree to assume the risk for any damage you, your patient, or your assistant may suffer due to (1) exposure to blood borne infectious agents such as HIV, HBV, and other microorganisms in the blood, (2) exposure to oral or respiratory secretions, or (3) other injuries occurring during the CRDTS examination. You agree to indemnify CRDTS (including its examiners) against and hold CRDTS (including its examiners) harmless from any and all losses, claims, demands, damages, assessments, costs and expenses (including reasonable attorneys' fees) of every kind, nature or description resulting from, arising out of or relating to the health care, status, or condition of you, your assistant, or your patient before, during, or after the examination.
  5. 5. Delays. If the administration of the exam is prevented or delayed by any cause or causes beyond the reasonable control of CRDTS, including, but not limited to: power outage at the School; acts of nature; acts of criminals or public enemy; war; riot; official or unofficial acts; inability to secure materials; restrictive governmental orders, regulations or laws; third-party labor disputes or strikes; or any other cause not the fault of or beyond the contract of CRDTS (collectively referred to as "Events"), then you acknowledge and agree that CRDTS will not be responsible or liable for any delay, cost, expense, or inconvenience caused as a result of an Event.
VIII. Candidate Signature


Prev Page Complete
Complete Application





Current Address:


School of Graduation (year):


Continuing Education Course:


Taking Exam

Exam(s):


Previous Exams:

Hygiene:

Taking Exam
Exam(s):

Previous Exams:

Restorative Auxiliary:

Taking Exam
Exam(s):

Previous Exams:

Additional Considerations:
 
 
Electronic SignatureDate

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