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 Written 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:

Written Exam

Clinical Practice Evaluation (CPE)

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.

0 of 3000 max 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.

Printed Name:*

Date:*

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

NDAEB Appeal Application

Appeal Request Details

Written 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

Written 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