To apply for a retired volunteer license to practice dentistry or dental hygiene, a dentist or dental hygienist shall submit: 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”; A certified letter with a raised embossed seal from the licensing authority of each state in which the applicant holds an active dental or dental hygiene license, or ever held an active dental or dental hygiene license, indicating that the license is or was in good standing and whether the applicant: Is being investigated; Has charges pending against the applicant's license; Has been disciplined; or Has 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 copy of the applicant's National Practitioner Data Bank file; A notarized affidavit stating that the dentist or dental hygienist will donate at least 100 hours of dental or dental hygiene services without compensation; Evidence that the dentist or dental hygienist is covered by malpractice insurance as set forth in Regulation .04 of this chapter; 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.