Form Yg(5095eq)f2 - Application For Yukon Registration Dental Hygienist/dental Profession Act Page 3

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STATUTORY DECLARATION
DENTAL PROFESSION ACT
In the matter of my application for registration and licensure with Yukon, I __________________________________________
Print name in full
of
in the province/territory of ___________________________________________
City
DO SOLEMNLY DECLARE:
1.
that I am the person referred to in the documents submitted in support of my application, and that these documents
present a true and accurate account of my qualifications; and
2.
that I authorize the licensing authorities and persons named herein to give such information to the Yukon licensing
authority as required;
and I make this solemn declaration conscientiously believing it to be true.
Declared before me at
in
City
Province/Territory
this ___________________________________ day of _____________________________________ , 20 _______________
Signature & Seal of Notary Public
Signature of Applicant
YG(5095EQ)F3 Rev.03/2014
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