Application For Yukon Registration Specialist Dentist/dental Profession Act Form Page 2
Download a blank fillable Application For Yukon Registration Specialist Dentist/dental Profession Act Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application For Yukon Registration Specialist Dentist/dental Profession Act Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
310. Year you achieved certification with the Royal College of Dentists of Canada: __________________________________
11. Have you ever been the subject of an inquiry?
☐ No
☐ Yes
If yes, state facts (attached additional pages if required): ___________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
12. Have you ever been convicted of any criminal offence?
☐ No
☐ Yes
If yes, state facts: _________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
I, ______________________________________________________________________________________________
Print name in full
hereby make application for registration and licensure in Yukon in accordance with the Dental Profession Act.
_________________________________________________________________________________________________
Signature of Applicant
In support of my application, I enclose:
1.
Completed application form.
2.
Required registration and licensing fees.
3. A certified copy of the document(s) which legally entitles me to reside and work in Canada.
4. • Certificate as a dental specialist issued by a regulatory authority in another Canadian jurisdiction that is party to the
Agreement on Internal Trade; and
• a Letter of Standing from the authority that issued this licence;
NOTE: It is not necessary for an individual to also hold a general Yukon practice licence in order to be registered as a
specialist. However, if you are licensed in both registers, continuing education requirements will apply for each licence.
The fee schedule is as follows:
Specialist Dentist — Resident
Specialist Dentist — Non-resident
(working in Yukon 3 months or less in licensing year)
Registration
$400
☐
Registration fee
$50
☐
Annual licence fee
$200
☐
Annual licence fee
$50
☐
NOTE: If you are a specialist dentist who also holds a general Yukon registration as a dentist, please call Professional Licensing and
.
Regulatory Affairs at 867-667-5111 for applicable fees
Please fill out this form, print, sign and return your documents and fees to:
Mail:
Courier or Dropoff address:
Professional Licensing and Regulatory Affairs, C-5
Professional Licensing and Regulatory Affairs, C-5
Box 2703
307 Black Street
Whitehorse, Yukon Y1A 2C6
Whitehorse, Yukon Y1A 2N1
Please make your cheque payable to Government of Yukon, or complete payment information form YG5924
at:
Important Note: Professional Licensing and Regulatory Affairs will NOT accept payment by email or fax
Please contact Professional Licensing and Regulatory Affairs at 867-667-5111 or fax 867-667-3609 or e-mail PLRA@gov.yk.ca for inquiries
YG(5769EQ)F3 Rev.3/2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal