Any person registered and currently licensed as a dental hygienist who has been practicing as a dental hygienist in Missouri immediately preceding the date of his application under the continuous supervision of a registered and currently licensed dentist in Missouri, 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 dental hygienist on the ______ day of ______, 20______, and has been practicing as a dental hygienist continuously under the supervision of a duly registered and currently licensed dentist 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 as a dental hygienist in the state of ______; provided that the required fee shall accompany each application.