2024 NELDA

Application Packet

Includes applications for the following exams:

• National Entry Level Dental Assistant (NELDA)
AMP, ICE and RHS exams taken in the same administration
• Anatomy, Morphology and Physiology (AMP)
• Infection Control (ICE)
• Radiation Health and Safety (RHS)
• RHS/ICE

DANB Contact, Forms and Policies

Dental Assisting National Board 1-800-367-3262
444 N. Michigan Ave., Suite 900 [email protected]
Chicago, IL 60611-3985
www.danb.org

Find all of DANB’s policies and forms at www.danb.org/exams/forms-and-policies.

DANB accepts 2024 exam applications through Dec. 31, 2024.

 CONTENTS AND GENERAL INFORMATION

Congratulations on taking the first step toward earning DANB certification!

Earning DANB certification is one of the most important steps you can take in your career. DANB offers national certification
exams, exams leading to certificates of knowledge-based competence and state-specific dental assisting exams. When
you earn and maintain DANB certification, you demonstrate your professional commitment and show you have gained the
education and experience to deliver a high standard of care.

Candidate Handbook
When applying for an exam, you are responsible for
Table of Contents
understanding and complying with policies and procedures Exam Eligibility....................................................3
in the Candidate Handbook.
Applying for an Exam..........................................5
Preparing for Your Exam Scheduling and Changing
1. Review the exam outline an Exam Appointment.....................................6
The exam outlines list the topics that will be covered on the Application Statements.......................................8
exams and can help you identify areas you’ll want to study.
Background Information Policy...........................9
2. Select your study materials
Obtain study materials. Options include: Form ................................................................10
• Suggested reference list (included in exam outlines)
• Textbooks and other reference materials
• The DALE Foundation’s review courses and study aids

3. Make a study plan

See study strategies and exam day tips at www.danb.org/exams/prepare-for-danb-exams.

NELDA Exam Outlines and References

• Anatomy, Morphology and Physiology (AMP)
• Infection Control (ICE)
• Radiation Health and Safety (RHS)

Fair Testing Policy

DANB seeks to ensure a fair and equitable testing experience for all individuals while ensuring the security and reliability
of the process. Improper behavior is not acceptable before, during or after an exam appointment, and each candidate’s
behavior is monitored during testing. Consequences of improper behavior may include recission of exam results and/or
revocation of ability to take future exams. For examples of improper behavior, see DANB’s Disciplinary Policy & Procedures,
available at www.danb.org.

We value your feedback and encourage you to share information about your experience. Please email [email protected] to
provide feedback about your experience, including the application process or your experience on testing day.

© 2024 Dental Assisting National Board, Inc. The following marks, either registered or unregistered trade, service and certification marks, are owned by the
Dental Assisting National Board, Inc. (DANB) and protected and monitored with the United States Trademark and Patent Office: NELDA®, CDA®, COA®, CPFDA®,
CRFDA®, CDIPC®, DISIPC®, CDPMA®, COMSA®, DANB®, Dental Assisting National Board®, RHS®, ICE®, Measuring Dental Assisting Excellence®, Certified Dental
Assistant™, Mark of Dental Assisting Excellence™, and the DANB logo. Use of these marks is strictly prohibited, except as provided in the Usage Guidelines for
DANB Trademarks, without the express written permission of DANB.

DANB is a member of the Institute for Credentialing Excellence. The National Commission for Certifying Agencies (NCCA), an Institute for
Credentialing Excellence commission with responsibility for accrediting certification programs, has evaluated DANB national certification programs
(CDA and COA), including DANB component exams (RHS, ICE, GC and OA), and finds that DANB programs meet NCCA’s highest standards, thus
helping to assure validity, reliability and objectivity in the testing process.

2 NELDA 2024 Application Packet (updated 03/26/24)

 EXAM ELIGIBILITY

NELDA Certification
Please note: Documentation is not required to take the NELDA exam or its component exams. Candidates only need to
submit eligibility documentation after they have passed all three exams within three years and DANB has sent the certification
application packet to the candidate requesting the required documentation.
You must meet the requirements of one of the eligibility pathways below to qualify to earn certification.
Once you earn the NELDA certification, you will be required to renew it annually. Because it is an entry-level certification,
NELDA can be renewed no more than three times, and held for up to four years. Please visit DANB’s website for more
information on DANB’s certification renewal requirements.
All NELDA certification pathways require current DANB-accepted, hands-on CPR, BLS or ACLS (see p. 4).

m PATHWAY I
Successful completion of a DANB-accepted dental assisting program located within a post-secondary institution that is
accredited by an organization recognized by the U.S. Department of Education. The program must NOT be accredited by
the Commission on Dental Accreditation (CODA). The program must be on DANB’s list of accepted programs.
AND
High school graduation or its equivalent.
Required Documentation
Successful completion of a dental assisting program within a post-secondary institution:
• Copy of certificate or diploma OR
• Copy of a transcript including date of completion
AND
High school graduation or equivalent:
• Copy of diploma, GED certificate or copy of a transcript from an institution recognized in the U.S. or Canadian
education system OR
• Proof of college or postsecondary coursework at an institution accredited by a U.S. Department of Education-
recognized agency
If high school is outside U.S. and Canada:
• Copy of high school or postsecondary diploma/transcript with graduation date
• Copy of document translated into English
• Copy of an equivalency report from any member of the National Association of Credential Evaluation Services

m PATHWAY II
Graduate of a U.S. Department of Labor Job Corps dental assisting program.

Required Documentation
Graduate of a Job Corps dental assisting program:
• Copy of certificate or diploma OR
• Copy of transcript mailed in a sealed envelope

m PATHWAY III
Successful completion of a DANB-accepted dental assisting program located within a high school or high school-level
career technical school that is recognized by that state’s Department of Education. The program must encompass at least
one semester of dental assisting curriculum. The high school or high school-level career technical school must be on
DANB’s list of accepted programs.

Required Documentation
Graduate of a high school dental assisting program:
• Letter from principal, dean of students or guidance counselor on school letterhead (including candidate’s name,
name of the program, program completion date, signed and dated by principal, dean of students or guidance
counselor) OR
• Copy of diploma OR
• Copy of a transcript including date of graduation

3 NELDA 2024 Application Packet (updated 03/26/24)

 EXAM ELIGIBILITY

m PATHWAY IV
Minimum 300 and up to maximum of 3,000 hours work experience as a dental assistant in any general or specialty
dental practice or setting, accrued over a period of at least two months and no more than three years; must be verified
by a licensed dentist.
AND
High school graduation or its equivalent.

Required Documentation
Completed Employer Work Experience Statement
AND
High school graduation or equivalent:
• Copy of diploma, GED certificate or copy of a transcript from an institution recognized in the U.S. or Canadian
education system OR
• Proof of college or postsecondary coursework at an institution accredited by a U.S. Department of Education
recognized agency
If high school is outside U.S. and Canada:
• Copy of high school or postsecondary diploma/transcript with graduation date
• Copy of document translated into English
• Copy of an equivalency report from any member of the National Association of Credential Evaluation Services

CPR, BLS or ACLS

All NELDA certification pathways require current DANB-accepted, hands-on CPR, BLS or ACLS.

Required Documentation
Copy of the certificate or front and back of the card that includes issue and expiration dates, instructor’s name and your
name and/or signature. Must be current at time of application for the certificate.

DANB accepts CPR, BLS and ACLS from the providers below, and only if the course included CPR and a hands-on exam.
Courses from other providers will not be accepted.

• American CPR Care Association* • EMS Safety Services

• American CPR Training • Medic First Aid
• American Emergency Response Training • Medical Training Associates
• American Environmental Health and Safety • Military Training Network
• American Health Care Academy* • National Safety Council (Green Cross)
• American Heart Association • Pacific Medical Training (BLS only through
• American Red Cross https://911coned.com)
• American Safety and Health Institute • ProCPR*
• Canadian Red Cross • Saudi Heart Association
• Emergency Care and Safety Institute • Save A Heart of Utah
• Emergency First Response *Not all courses include a hands-on exam. Contact provider to
• Emergency Medical Training Associates be sure the course includes a hands-on skills assessment and
• Emergency University* will be accepted by DANB.

4 NELDA 2024 Application Packet (updated 03/26/24)

 APPLYING FOR AN EXAM

Exam Timeline

DANB ID Policy
When taking an exam, you must present one form of identification (ID) at your exam appointment.
Your ID must be:
• Currently valid, non-expired • Government-issued
• Photo-bearing • Signature-bearing
• In Roman characters • The exact name as listed in their online DANB account

The printed name on your ID must match your name as it appears in DANB’s database. Differences due to marital status
changes without supplemental documentation are not allowed. The middle name is not required and does not need to be
spelled out, but, if used, the first letter of the middle name must match the spelled-out name. The ID must be original; copies
of IDs are not acceptable.

If the name listed on your account does not exactly match your ID, a Name Change Request must be processed through
your DANB Dashboard with acceptable documentation. Contact DANB if any assistance is needed.

Acceptable forms of identification include:

• U.S. driver’s license • U.S. ID card/State ID card

• Valid passport • A U.S. government-issued permanent resident card
• Military ID card

Candidates who are under the age of 18 taking an online proctored exam are permitted to present a valid student ID as a
form of identification, as long as their parent or legal guardian presents a DANB-accepted form of ID during check-in. In
addition, for exams administered through online proctoring, the candidate’s guardian must provide verbal consent during the
check-in process.

Candidates will not be allowed to take the exam if the name on their ID does not match the registered name exactly, and they
would need to reapply. See the Missed Exam Appointment section for details.

Nondiscrimination Policy
DANB does not discriminate in application, examination, or certification activities on the basis of age, sex, gender identity,
gender expression, pregnancy, ancestry, marital status, citizenship or immigration status, status as a veteran, race, ethnicity,
color, religion, national origin, sexual orientation, other non-medically relevant factors, physical, mental or other disability, or
medical condition.

Accommodations for Candidates with Documented Disabilities

Please see the Reasonable Accommodations form for complete information on accommodations. Accommodations requests
must be received with original application/prior to authorization.

5 NELDA 2024 Application Packet (updated 03/26/24)

 SCHEDULING AND CHANGING AN EXAM APPOINTMENT

Scheduling an Exam Appointment

Once your application is approved, you will receive a notification from DANB by email that provides a link to schedule your
exam at a test center. You will have 60 days from the date your application is approved to schedule and take your exam.
You should schedule the exam appointment as soon as you receive an email from DANB, as appointments may be limited.
Instructions are provided by email and within your online DANB account to schedule the exam appointment. Specific in-
person test center locations, dates or times cannot be guaranteed; changes to in-person test center locations and/or hours
may occur without notice.

Canceling or Rescheduling an Exam Appointment

All exams can be canceled or rescheduled online through Pearson VUE. Exams scheduled at a test center can be canceled
or rescheduled up to 24 hours before the appointment time. Online proctored exams can be canceled or rescheduled up until
the time of the exam. To cancel or reschedule your exam, please follow the steps below:
1. Log in to your DANB account to access your DANB Dashboard.
2. Select the exam you would like to reschedule under the heading “Applications in Process.”
3. Click the “Schedule Exam” button.
4. Select your upcoming exam appointment within your Pearson VUE Dashboard.
5. Follow the prompts to cancel or reschedule your exam. Don’t forget the last step, which includes a “Confirm” button.
6. Verify your new appointment or cancellation details in the automated email sent from Pearson VUE. If you did not
receive an email from Pearson VUE, your exam appointment has not been canceled or rescheduled.

Requesting a New Testing Window

If you cannot schedule or reschedule an exam appointment before the end of your original 60-day testing window, you may
request a new 60-day testing window one time. The request must be submitted within 60 days after the end of your original
testing window. If you do not take the exam within the new testing window, you must submit a new exam application with any
required documentation and full fees. Any testing window received at a reduced fee is not eligible for a refund. For additional
information, please see the required Request a New Testing Window form.

Canceling a Testing Window and Requesting a Partial Refund

If you do not wish to take the DANB exam for which you applied and would like to request a partial refund, you must submit a
Request to Cancel a Testing Window form. For additional information, please see the required form.

Missed Exam Appointment

Any exam that is missed for any reason other than a documented emergency may be rescheduled at a reduced fee ONE
TIME by following the below steps:
1. Access the exam application on your DANB Dashboard by clicking the name of the missed exam, AND
2. Submit a request and payment for the new 60-day testing window within 60 days of the Missed Exam date. The new
testing window will start immediately upon successful submission of the request.
Exams are considered missed if you were not able to take your scheduled exam for any reason. This includes but is not limited
to arriving late, providing an unacceptable ID, confusion over appointment details, and any technical issues for online testing.

If you do not submit your request within 60 days, you must reapply for the exam with the full fee.

For online proctored exams: You must complete the check-in process no later than 15 minutes after the start of your
scheduled exam appointment or your appointment will be declared missed. During the exam check-in process, if there are
any technical issues, including an unstable internet connection, or you cannot meet the setup procedures, it may delay the
check-in process and/or cause you to miss your scheduled exam. Exams can only be held for 15 minutes past the exam start
time, so it is your responsibility to ensure that all necessary check-in steps have been successfully completed prior to that
time to begin exam delivery. If you experience internet problems during your exam, such as an unstable internet connection,
the exam may not be successfully delivered. If this happens, your exam will be recorded as missed and no refund will be
provided.

6 NELDA 2024 Application Packet (updated 03/26/24)

 SCHEDULING AND CHANGING AN EXAM APPOINTMENT

Missed Exam Appointment Due to Emergency

At discretion, DANB may issue candidates a new 60-day testing window with no additional cost for qualifying emergencies. To
submit a request for a new testing window, following an emergency, you must:
1. Access the exam application on your DANB Dashboard by clicking the name of the missed exam, AND
2. Submit a request with a description of your emergency with dated supporting documentation within 60 days of the
missed exam appointment.
Requests will be reviewed within 3-5 business days. Approved requests will receive a new 60-day testing window at no
additional fee. If an emergency is denied, please see Missed Exam Appointment section above.

7 NELDA 2024 Application Packet (updated 03/26/24)

 APPLICATION STATEMENTS

Application Statements
Please read the following Application Statements carefully. The Application Statements apply to all DANB-administered
national and state-specific exams, certificate and certification renewal applications. The candidate’s signature on the
application indicates understanding and agreement to be legally bound by these statements.

1. I hereby apply to the Dental Assisting National Board, Inc. (DANB) for examination, a certificate and/or certification, in accordance with and subject to the
procedures and policies of DANB and the regulations and requirements of any state agency on behalf of which DANB administers an exam or certificate
program. Under penalty of perjury, I declare that the information provided on my application is true. I have read and agree to the requirements and
conditions set forth in the DANB application packet, and the Candidate Handbook or State Candidate Handbook if applicable, covering eligibility for and the
administration of exams, certificates, the certification process, and DANB policies, including but not limited to DANB’s Code of Professional Conduct and
DANB’s Disciplinary Policy & Procedures. I agree to disqualification from the exam, to denial of an exam result, certificate or certification, and to forfeiture
and return to DANB of any exam result, certificate granted me by DANB, in the event that any of the answers or statements made by me in this application
are false, or in the event that I violate any DANB rules or policies. I agree to comply with any investigation in which I am named, and I authorize DANB to
make whatever inquiries and investigations it deems necessary to verify my eligibility, credentials or professional standing.

2. I hereby release DANB, its directors, officers, examiners and agents from any and all liability arising out of or in connection with any action or omission by
any of them in connection with this application, the certification process, any exam administered by DANB, any scoring relating thereto, the failure to issue
me an exam result, certificate, or any demand for forfeiture or return of such exam result, certificate, and I agree to indemnify DANB and said persons and
hold them harmless from any lawsuit, complaint, claim, loss, damage, cost or expense, including attorneys’ fees, arising out of or in connection with said
credentialing activities which include all DANB-administered exams and certificates. I UNDERSTAND THAT THE DECISION AS TO WHETHER I HAVE MET
REQUIREMENTS FOR ADMISSION TO A DANB-ADMINISTERED EXAM OR RECEIPT OF A DANB-ADMINISTERED EXAM RESULT, CERTIFICATE OR
CERTIFICATION RESTS SOLELY AND EXCLUSIVELY WITH DANB AND THAT THE DECISION OF DANB IS FINAL. Notwithstanding the above, should I file
suit against DANB, I agree that any such action shall be governed by and construed under the laws of the State of Illinois without regard to conflicts of law.
I further agree that any such action shall be brought in the Circuit Court of Cook County in the State of Illinois, or the United States District Court for the
Northern District of Illinois; I consent to the jurisdiction of such state and federal courts; and I agree that the venue of such courts is proper. I further agree
that should I not prevail in any such action, DANB shall be entitled to all costs, including reasonable attorneys’ fees, incurred in connection with the litigation.

3. I understand that except as provided below, this application and any information or material received or generated by DANB in connection with this
application or the exam process will be kept confidential and will not be released unless I have authorized such release or the release is required by law. I
understand that DANB will verify receipt of any DANB exam application and the date received, on request. I further understand and agree that DANB may
also provide verification to anyone by phone, by mail or on DANB’s website regarding whether I hold any DANB certifications, any DANB certificates of
knowledge-based competence and any state-specific certificates administered by DANB on behalf of a state regulatory body. Phone and mail verification
will be provided to anyone upon request and will consist of oral or written confirmation of whether I hold any DANB-administered credentials and the
effective dates for each credential. Online verification through DANB’s website may consist of online display of my name, the DANB-administered credentials
I hold and dates earned, current DANB certification status, and my city and state of residence. My full address will not be posted online by DANB. I further
understand and agree that DANB may, from time to time, provide my name, address, phone number to third parties (including but not limited to official
DANB affiliates, potential employers; dental conference sponsors; federal, national or state organizations; or legislative committees or task forces proposing
or informing stakeholders of legislation). I further understand that this consent will remain in effect unless and until I submit a written request to have this
information omitted from release. I understand that if I do not want DANB to display my city and state of residence as part of the online verification process,
then I must submit a written request for omission of this information to the following address: DANB Communications Department, 444 N. Michigan Ave.,
Suite 900, Chicago, IL 60611. I understand that my name, credentials held [issued by DANB as described above] and current DANB certification status will
be displayed for everyone; opting out of display of information is only possible for an individual’s city and state.

4. I understand that by providing my email address and phone number on the application form, or by providing it through my online DANB account, I am
consenting to receive email or text messages from DANB and its official affiliates related to their products and services or news affecting the oral healthcare
profession. I understand that DANB agrees not to provide my email address to any other third party, excluding federal, national or state regulatory bodies,
without my consent, and that I can request removal from DANB’s email distribution list by following the directions contained in the Privacy Policy section of
DANB’s Terms and Conditions of Use of DANB.org, located at www.danb.org.

5. I authorize DANB to release my exam results and credential status to state regulatory agencies. Individuals cannot opt out of DANB release of exam results
or credential status to state regulatory agencies. I also authorize DANB to use information from my application and exam(s) for statistical analysis, providing
that any personal identification is deleted.

6. I understand that I can be disqualified from taking or continuing to sit for an exam, from receiving exam results or certificate and from obtaining
certification if DANB determines through proctor observation, statistical analysis or any other means that I was engaged in collaborative, disruptive or other
unacceptable behavior before, during the administration of, or following the exam.

7. I understand that the content of all DANB exams is proprietary and strictly confidential information. I hereby agree that I will not disclose, either directly or
indirectly, any question or any part of any question from the exam to any person or entity. I understand that the unauthorized receipt, retention, possession,
copying or disclosure of any DANB exam materials, including but not limited to the content of any exam question, before, during or after the exam may
subject me to legal action. Such legal action may result in monetary damages and/ or disciplinary action including rescinding exam results and denying
or revoking certification. I agree to comply with any investigation regarding my behavior, acts or omissions, related to DANB exams, certificates and/or
certifications.

8. I understand that for each application submitted, DANB will process the appropriate payment. If I fail to show up for an exam for which I have applied, and
there is no documented DANB-accepted emergency, and I failed to comply with DANB cancellation policies, I am still obligated to pay the full exam fee. I
further understand that taking the exam and then revoking payment constitutes the wrongful use of DANB products and services and I may be subjected to
legal action. I am obligated to pay for the exam whether I pass or fail. I agree not to dispute the exam fee. Exam results will be rescinded if the exam fee is
not paid in full.

8 NELDA 2024 Application Packet (updated 03/26/24)

 BACKGROUND INFORMATION POLICY

Background Information Policy

National exam, certification renewal, certification reinstatement, and emeritus applications contain three background
information questions (BIQs) that exam candidates and certificants (“DANB Individuals”) are required to answer. Failure
to answer the questions will result in the application being returned as incomplete. DANB Individuals must submit
documentation, with their completed application, related to each affirmative response. DANB will review the documentation
related to each affirmative response and make a case-by-case determination, in consultation with legal counsel, as to the
candidate’s eligibility to test, to earn certification or recertify. Dependent on specific disclosures made. DANB reserves the
right to bring individuals for review under DANB’s Disciplinary Policy & Procedures.

Note: Any person being held on criminal charges or serving a sentence of confinement (e.g., prison, jail, home detention, or
any equivalent mode of confinement) for any offense, must be fully released from confinement before applying for and/or
taking a DANB exam or before renewing or reinstating DANB certification.

BACKGROUND INFORMATION QUESTIONS — DANB NATIONAL EXAM APPLICATIONS

BIQ 1 Is your answer “yes” to either of the following?
• In the last five years, have you been convicted of, or pled guilty or no contest to, a felony or any crime punishable by
confinement in a state or federal prison for any length of time?
• Are you currently serving a sentence of confinement, home detention, parole, probation, or other court-ordered
supervision, or are you subject to a reporting requirement (e.g., sex offender or violent offender registry) in connection
with any felony conviction received in your lifetime?
It is not necessary to report misdemeanor convictions. If you are uncertain whether a conviction was for a felony or a
misdemeanor, you must mark “yes.”

BIQ 2 Have you ever been the subject of any of the following?
• Suspension, revocation, or voluntary surrender of your dental assisting license, registration, or other state recognized
dental assisting credential?
• Suspension, revocation, or voluntary surrender of a license, registration, or other state-recognized credential in any
profession?
• Loss of authorization to practice dental assisting or any profession as an employee of the federal government?
• Loss of authorization to practice dental assisting or any profession in a jurisdiction that does not require registration,
licensure, or other recognized employment credential?
• Disciplinary action by a professional regulatory board, certifying or examination agency, or other professional body?
• Investigation by or dismissal from an educational institution or employer for cheating, violating an educational
institution’s or other organization’s code of conduct or similar document, or any other ethical violation?

BIQ 3 Have you ever been declared mentally incompetent by a court of law?

DOCUMENTATION REQUIRED IF A CANDIDATE ANSWERS “YES”

Documentation must be submitted with the completed exam application.

Step 1 — Personal Statement

The candidate must attach a signed and dated personal statement describing the circumstances surrounding each
occurrence, the offense or reason for the conviction or disciplinary action, the date of the adverse action, the penalties
imposed, and the dates when penalties for each occurrence were or will be completed.
Step 2 — Supporting Documentation
The candidate must also provide official documentation related to each occurrence, including but not limited to:
BIQ 1 For felony convictions, judgment of conviction, sentencing order and termination of probation order, if applicable,
and any other documentation deemed necessary by DANB.
BIQ 2 For regulatory, credentialing or educational disciplinary action an official statement from the disciplining agency
or educational institution describing the offense and penalties imposed (e.g., consent order, decision) and, if applicable,
providing evidence of completion or expiration of all penalties, including reinstatement of license or credential.
BIQ 3 For a court declaration of mental incompetence, official copies of all relevant court orders and related
documents.

9 NELDA 2024 Application Packet (updated 03/26/24)

 2024 National Entry Level Dental Assistant (NELDA) Exam
This application will be accepted through Dec. 31, 2024.
1. Candidate must sign, date, answer all background information questions, and submit all required documentation and fees to DANB. Incomplete
applications will be not be processed. DANB will return the payment, minus a $75 application fee and any nonrefundable certificate fees, to
the candidate.
2. Mail or email completed application and any required documentation to DANB. Full payment is required at the time of application.

Section A: Exams (Please type or print with a pen.)

What exam are you applying for? NELDA exam (AMP, ICE, RHS exams taken together)
AMP exam only ICE exam only RHS exam only RHS/ICE

Section B: Signature and Date (Please sign and date with a pen.)
I hereby affirm that my answers to all questions are true and correct, I have met all eligibility requirements, and I will comply with all DANB policies and procedures. I affirm that I will abide by the
security protocols of DANB’s testing vendor(s), including a palm vein scan at the testing center. I further affirm that I have read and understood the Application Statements contained in this packet,
and I intend to be legally bound by them. I understand that the $75 application fee is not refundable under any circumstances.

Signature Date

Section C: Background Information Questions (Please type or print with a pen.)

Read the questions in their entirety on page 9. If you checked Yes for any question, you must include required documentation.

1. In the last five years have you been convicted 2. Have you ever been disciplined by a regula- 3. Have you ever been declared mentally incom-
of any felonies or are you currently serving any tory board, certifying or examination agency, or petent by a court of law?
sentences for felony convictions? education institution?
No Yes No Yes No Yes

Section D: Candidate Information (Please type or print with a pen.)

In what state do you work? Last 4 SSN Date of Birth / /
* Are you 18 years of age or older? Yes No If you are under the age of 18 and applying for an exam that offers online remote proctoring, you will
be required to submit the Parent/Guardian Consent Form, which can be found on the DANB website.
Name (must match current ID exactly or you may be turned away from your appointment):

* Last * First Middle Name/Initial

* Email (required) Prior Name (if applicable)

* Home Address * City * State * Zip

* Phone Numbers (at least one is required):
Office Cell or Home

Section E: Education/Experience (check all that apply)

On-the-job-trained dental assistant Years of experience /
Visit www.danb.org
years months
for a list of program
Non-CODA-accredited dental assisting program Grad Year/Anticipated Grad Year Program code
codes.
Completed a course

Section F: Payment Exam fees include the $75

nonrefundable application fee DANB use:
Candidate’s Name NELDA exam (3603)
AMP exam (3661)
NELDA Fee AMP Fee ICE Fee RHS Fee RHS/ICE Fee ICE exam (3630)
RHS exam (3625)
Traditional candidate $400 $245 $270 $270 $375 RHS/ICE exam (3616)

Active military personnel $380 $240 $265 $265 $365

Check/Money Order payable to DANB (must include candidate’s name and be in U.S. dollars)

Credit Card Authorization (VISA, MasterCard, Discover & American Express accepted): Amount $
Credit Card Number CVV Expiration /

Cardholder’s Name Cardholder’s Signature

Cardholder’s Billing Address City

State Zip Daytime Phone Number

By signing, the cardholder acknowledges intent to register for the aforementioned DANB exam in the amount of the total shown hereon and agrees to perform the obligations set forth in the cardholder’s
agreement with the issuer. Furthermore, the cardholder understands that the signature obtained at the exam administration shall be used to indicate receipt of purchase. A candidate who fails to show
up for the exam for which they registered and has not canceled the exam as described in this packet is still required to pay for the exam. (See the Application Statements for further requirements.)

Mail: DANB • 444 N. Michigan Ave., Suite 900 • Chicago, IL 60611 Email to: [email protected]
Questions? 1-800-367-3262 or [email protected] Do not submit twice or you will be charged twice.

10 NELDA 2024 Application Packet (updated 12/13/23)