Form Yg(5097eq)f3 - Application For Yukon Registration Dentist/dental Profession Act

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APPLICATION FOR YUKON REGISTRATION

DENTIST

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.

☐

Name in full: ___________________________________________________________________Gender:

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: ___________________________

Clinic Name

dd/mm/yyyy

Clinic Address: ____________________________________________________________________________________

City

☐

___________________________________________________________________________________ Mail to Clinic

Province/Territory

Postal code

Clinic telephone number

Are you presently licensed to practise in another jurisdiction?

☐ No

☐ Yes

If yes, where? ____________________________________________________________________________________

Limitations, restrictions or conditions on this licence:

☐ No

☐ Yes

If yes, please give specific details:

________________________________________________________________________________________________

Give addresses of all locations and dates in which you have practised as a 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:

10. Year you achieved certification with the National Dental Examining Board of Canada: ____________________________

yyyy

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(5097EQ)F3 Rev.3/2014