Application For Yukon Registration Specialist Dentist/dental Profession Act Form

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APPLICATION FOR YUKON REGISTRATION

SPECIALIST DENTIST

DENTAL PROFESSION ACT

Specialist Licence — An individual may hold a specialist registration only for a nationally recognized

dental specialty established by the Royal College of Dentists of Canada (RCDC).

Name of Specialty for registration: _____________________________________________________________

All information requested in this application must be provided. If application is not complete it will be

returned or rejected. Appropriate registration and annual licence fees must be enclosed.

Please allow 30 days for processing.

Name in full: ____________________________________________________________________ Gender: ☐ F

☐ M

Maiden name (if applicable): ________________________________________________________________________

Date of birth: ________________________________________________ Location ____________________________

dd/mm//yyyy

Home address of Applicant: ________________________________________________________________________

City

_______________________________________________________________________________________________

Province/Territory

Postal code

Home telephone number

Email address: ___________________________________________________________________________________

I expect to practise in: _________________________________________ starting on __________________________

dd/mm/yyyy

Clinic Name

Clinic Address: ___________________________________________________________________________________

City

_______________________________________________________________________________________________

Province/Territory

Postal code

Clinic telephone number

Are you presently licensed to practise in another jurisdiction?

☐ No

☐ Yes

If yes, where?

Give addresses of all locations and dates in which you have practised as a Specialist Dentist for the three years preceding

this application:

_______________________________________________________________________________________________

Provide a true chronological summary of your educational history giving names of institutions attended, dates of

attendance and degrees or diplomas received:

Institution:

Location:

Date of entering:

Date of Graduation:

Degree obtained:

Personal information contained on this form is collected under the Dental Profession Act and will be used for the purpose of administering the Act. For further

information, contact the Director of Director of Professional Licensing and Regulatory Affairs at (867) 667-5111, toll free within Yukon 1-800-661-0408, ext. 5111.

YG(5769EQ)F3 Rev.3/2014