Form Yg(5095eq)f2 - Application For Yukon Registration Dental Hygienist/dental Profession Act Page 2
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12.
Have you completed anaesthetic training?
No
Yes
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If yes, which anaesthetic method(s) are you qualified for
Infiltration
Mandibular block
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13.
Have you ever been the subject of an inquiry?
No
Yes
If yes, state facts (attached additional pages if required): __________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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14. Have you ever been convicted of any criminal offence?
No
Yes
If yes, state facts (attach additional pages if required): _____________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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.
• Dental Hygienist Certificate 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;
OR
• Certified copy of certificate of qualification from the National Dental Hygiene Certification Board; and
• Certified copy of graduate certificate from an accredited dental hygiene program; and
• Certified copy of anaesthetic training certificate if applicable
The fee schedule is as follows:
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Dental Hygienist
Registration ($100)
Annual licence fee ($50)
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
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
YG(5095EQ)F3 Rev.03/2014
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