Appeal Application Form

NDAEB Appeal Application

"*" indicates required fields

1Personal Information

2Appeal Details

3Fees and Payment

Appeal Request Details

Please complete the following form to appeal the results of your NDAEB Theory Examination or Clinical Practice Evaluation (CPE). Requests to appeal must be received by the NDAEB office no later than thirty (30) days after the date appearing on your results letter.

Name*

First Middle Last

Note: If you do not have a legal last name/surname, please enter a period (.) as a placeholder in the last name field.

NDAEB ID*

Please enter your assigned 8-digit NDAEB Applicant ID number.

Home Address*

Street Address/PO Box Suite/Apartment City State / Province / Region ZIP / Postal Code Country

Email Address*

Enter Email Confirm Email

Alternate Email Address

Enter Email Confirm Email

Primary Phone*

Alternate Phone Number

NDAEB Appeal Type*

I would like to appeal my NDAEB results for the following:

Theory Exam

Clinical Practice Evaluation (CPE)

Theory Exam Results Appeal Request

For more details on the appeal process for Theory Exam results please refer to the "Examination Appeals" section in the Theory Examination Candidate Handbook.

Clinical Practice Evaluation Results Appeal Request

For more details on the appeal process for Clinical Practice Evaluation (CPE) results please refer to the "Appeals" section in the Clinical Practice Evaluation Candidate Handbook.

Examination Session*

Select the examination session for which you wish to request an appeal of your results.

Clinical Practice Evaluation (CPE) Session

Select the Clinical Practice Evaluation (CPE) session for which you wish to request an appeal of your results.

CPE SittingLocation

Ground(s) for Appeal*

Select the ground(s) for appeal that apply to your selected session.

Procedural

Environmental

Personal

Reason(s) for Appeal*

Using the text editor provided below, please explain the reason(s) for the appeal including basis and evidence. You have a maximum of 3000 characters.

Evidence Document(s)*

Upload high quality scan(s) in PDF format of any document(s) you wish to include as evidence to support your appeal. Copies of all relevant evidence MUST be uploaded to this appeal form if you wish for them to be considered by the Appeals Committee.

Drop files here or

Accepted file types: pdf, Max. file size: 64 MB, Max. files: 3.

Note: Please refer to the "Examination Appeals" section in the Theory Examination Candidate Handbook for details regarding the required supporting document(s) for your appeal.

Note: Please refer to the "Appeals" section in the Clinical Practice Evaluation Candidate Handbook for details regarding the required supporting document(s) for your appeal.

NDAEB Notification*

Did you notify the NDAEB office about the circumstances above within one (1) week of the Theory examination?

Yes

Signature*

I request to appeal the results of my Theory examination based on the grounds and evidence provided on this form.

Signature*

I request to appeal the results of my Clinical Practice Evaluation (CPE) based on the grounds and evidence provided on this form.

Printed Name:*

Date:*

National Dental Assisting Examining Board
Bureau national d'examen d'assistance dentaire

NDAEB Appeal Application

Appeal Request Details

Theory Exam Results Appeal Request

Clinical Practice Evaluation Results Appeal Request

Appeal Fees and Payment Details

ADDRESS

CONTACT

OFFICE HOURS

ADDITIONAL INFO

National Dental Assisting Examining Board Bureau national d'examen d'assistance dentaire

NDAEB Appeal Application

Appeal Request Details

Theory Exam Results Appeal Request

Clinical Practice Evaluation Results Appeal Request

Appeal Fees and Payment Details

National Dental Assisting Examining Board
Bureau national d'examen d'assistance dentaire