Home General Fees General Fees Text field Thank you for choosing to pay for your service with the Board’s online payment option. This form is for paying for your duplicate certificate, license verification, business entity and penalty fees. Fields marked with an asterisk are required and must be completed prior to clicking Pay Now. A $2.00 Convenience Fee will automatically be added to your total. Customer Information First Name Last Name License Number # Email @ Phone Number # Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Products Options Additional Office Triennial Certificate - $25 Duplicate Wall Certificate - $25 (License Number required) Duplicate License - $25 (License Number required) License Verification (for Licensure in another state) - $25 (License Number required) Business Entity Initial Triennial Registration Fee - $300 Business Entity Renewal of Triennial Registration Fee - $300 Business Entity Late Registration - $100 Business Entity Replacement or Duplicate License Fee - $25 (Business License Number required) Penalty for Failure to Notify Board of a Change of Mailing Address - $100 Civil Penalty Administrative Penalty Mobile Dental Facility & Portable Dental Unit Permit Application - $200 Mobile Dental Facility & Portable Dental Unit Permit Renewal - $200 Mobile Dental Facility & Portable Dental Unit Permit Late Fee - $100 Additional Office Quantity - Select -12345678910 Duplicate Wall Certificate Quantity - Select -12345678910 Duplicate License Quantity - Select -12345678910 Business Entity Replacement or Duplicate License Quantity - Select -12345678910 Complaint Number # Civil Penalty Amount $ Administrative Penalty Amount $ Payment Detail Preview Leave this field blank