To apply for a volunteer license to practice dentistry or dental hygiene, a dentist or a dental hygienist who has passed a regional board in accordance with Health Occupations Article, §4-306, Annotated Code of Maryland, 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”; An original National Board Score Card; Certified proof of dental or dental hygiene 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 a regional board; A certified letter with a raised embossed seal from the dental or dental hygiene 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 licensee 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; 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 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 .09 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. In addition to the requirement of §A(5) of this regulation that a dentist submit a certified examination score of a regional board, a dentist, if requested by the State Dental Board, shall submit a specific point breakdown by procedure including penalty deductions.