An applicant who has passed the ADLEX with a score of 75 or greater in each required section shall submit the following to the Board: A completed application on a form provided by the Board; A photograph of the applicant not to exceed 3 inches by 3 inches accompanied by a notarized statement stating that “the photograph is a true photograph of me”; An original National Board Score Card; Certified proof of dental education which contains the raised embossed school seal certifying its authenticity, except that letters from educational institutions on original letterhead, bearing an original signature, do not require a raised embossed seal; A certified examination score of the ADLEX and, if requested by the Board, a specific point breakdown by procedure including penalty deductions if available; A certified letter with a raised embossed seal from the dental licensing authority of each state in which the applicant holds an active dental license or ever held an active dental license indicating that the license is or was in good standing and that the applicant: Is not being investigated; Does not have charges pending against the applicant's license; Has not been disciplined; and Has not been convicted or disciplined by a court of any state or country for an act that would be grounds for disciplinary action under Health Occupations Article, §4-315, Annotated Code of Maryland; Documentation of change of name if the name on any of the documents submitted to the Board differs from the applicant's name; and Any other documents or information pertinent to licensure required by the Board. An applicant who has not passed the ADLEX with a score of 75 or greater in each required section of the ADLEX shall submit the following to the Board: A completed application on a form provided by the Board; A photograph of the applicant not to exceed 3 inches by 3 inches accompanied by a notarized statement stating that “the photograph is a true photograph of me”; An original National Board Score Card; Certified proof of dental education which contains the raised embossed school seal certifying its authenticity, except that letters from educational institutions on original letterhead, bearing an original signature, do not require a raised embossed seal; A certified letter with a raised embossed seal from the dental licensing authority of each state in which the applicant holds an active dental license or ever held an active dental license indicating that the license is or was in good standing and that the applicant: Is not being investigated; Does not have charges pending against the applicant's license; Has not been disciplined; and Has not been convicted or disciplined by a court of any state or country for an act that would be grounds for disciplinary action under Health Occupations Article, §4-315, Annotated Code of Maryland; A notarized affidavit or other evidence satisfactory to the Board indicating that for the 5 preceding years the applicant has been actively engaged in practicing dentistry for at least 850 hours on average per year; Documentation of change of name if the name on any of the documents submitted to the Board differs from the applicant's name; and Any other documents or information pertinent to licensure required by the Board.