Form Yg(5097eq)f3 - Application For Yukon Registration Dentist/dental Profession Act Page 2
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311. 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
Signature of Applicant
hereby make application for registration and licensure in Yukon in accordance with the Dental Profession Act.
In support of my application, I enclose:
1.
Completed application form.
2.
Required registration and licensing fees.
3.
• Certificate as a dentist 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
Certificate of qualification from the National Dental Examining Board of Canada, and one of the following:
• Certified copy of Degree indicating graduation from a dental program accredited by the Commission of Dental
Accreditation of Canada or by the American Dental Association on Dental Accreditation; or
• Proof of completion of National Dental Examination Board of Canada equivalency program; or
• Proof of completion of a qualifying or degree completion program at an accredited Canadian university.
4.
A certified copy of the document(s) which legally entitles me to reside and work in Canada.
The fee schedule is as follows:
Dentist — Resident
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
Please fill out this form, print, sign and return your documents and fees to:
Mail:
Courier or Dropoff:
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(5097EQ)F3 Rev.3/2014
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