To apply for identification as a specialist, a licensed dentist shall submit to the Board: An application on a form that the Board provides; A fee as set forth in COMAR 10.44.20; and Either evidence of having successfully completed a Board-approved specialty training program or a written statement, under oath, that sets forth the basis for the dentist's claim that, before July 1, 1979, the dentist reasonably represented to the public that the dentist was a specialist in that specialty, including in that written statement the: Dates during which the dentist's practice was limited to that specialty; and Education and experience on which the claim to be a specialist was based.