Form Yg(5095eq)f2 - Application For Yukon Registration Dental Hygienist/dental Profession Act

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APPLICATION FOR YUKON REGISTRATION

DENTAL HYGIENIST

DENTAL PROFESSION ACT

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.

☐

1. Name in full: ___________________________________________________________________ Gender:

2. Maiden name (if applicable): _________________________________________________________________________

3. Date of birth: ________________________________________________ Location ______________________________

dd/mm/yyyy

4. Home address of applicant: __________________________________________________________________________

City

________________________________________________________________________________________________

Province/Territory

Postal code

Home telephone number

Email address: ____________________________________________________________________________________

5. I expect to practise in: _________________________________________ starting on ___________________________

Clinic Name

dd/mm/yyyy

Clinic Address ____________________________________________________________________________________

Street Address

City

☐

___________________________________________________________________________________ Mail to Clinic

Province/Territory

Postal code

Clinic telephone number

☐

Are you presently licensed to practise in another jurisdiction?

Yes

If yes, where? ____________________________________________________________________________________

☐

Limitations, restrictions or conditions on this licence:

Yes

If yes, please give specific details

________________________________________________________________________________________________

8. Place of Graduation: _______________________________________________________________________________

9. Year of Graduation: ____________________

yyyy

☐

10. Did you pass the National Dental Hygiene Certification Board Exam?

Yes

If yes, Written: ________________________________________Clinical: ______________________________________

dd/mm/yyyy

11. Give addresses of all locations and dates in which you have practised as a dental hygienist for the three years preceding

this application:

________________________________________________________________________________________________

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

YG(5095EQ)F3 Rev.03/2014