Any registered and currently licensed dentist of good moral character who has been practicing dentistry in Missouri immediately preceding the date of his application may apply to the board for a certificate to be signed and attested by a designee of the board and bearing the board’s seal, certifying that the holder is a person of good moral character, that he was registered and licensed in Missouri as a dentist on the ______ day of ______, 20______, and has been practicing dentistry continuously in Missouri for ______ year(s) immediately preceding the date of the certificate, and that he has represented to the board that he intends to apply to practice dentistry in the state of ______; but the required fee shall accompany each such application.