Application Form For Licensure As A Dental Specialist
Download a blank fillable Application Form For Licensure As A Dental Specialist in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Application Form For Licensure As A Dental Specialist with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4DEN
STATE OF ALASKA
DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT
DIVISION OF OCCUPATIONAL LICENSING
BOARD OF DENTAL EXAMINERS
333 Willoughby Avenue, 9th Floor
P.O. Box 110806
Juneau, Alaska 99811-0806
(907) 465-2542
E-mail: license@dced.state.ak.us
APPLICATION FOR LICENSURE AS A DENTAL SPECIALIST
I hereby apply for:
Specialty Dental License Fee: $100.00
Permit to Administer General Anesthetic Agents: $100.00
Application Fee: $50.00 (Only one application fee due if you are applying at the same time for both a specialty license and
general anesthetic permit)
The application fee is nonrefundable should you decide to withdraw your application or you are denied.
I submit the following statements, under oath, and enclose the required documents and fees:
INSTRUCTIONS TO THE APPLICANT
It is the responsibility of the applicant to ensure that all information requested in this application is received. Each question
must be answered fully, truthfully, and accurately. Any omissions or inaccuracies are grounds for disapproval and rejection.
Section 08.36.315(1) of the Dental Practice Act provides that knowingly cooperating in deceit, fraud, or intentional misrepresentation
to obtain a license is cause for suspension, revocation, or annulment of licensure. If the space for any answer is insufficient, the
applicant may complete his/her answer on a rider signed by him/her and specifying the number of the question to which it relates.
Type or print all requested data.
1.
Name in full
S.S. No.
Last
First
M.I.
2.
Mailing Address
City
State
Zip Code
3.
Residence Address
City
State
Zip Code
4.
Office Address
City
State
Zip Code
5.
Date of Birth
6.
GENERAL DENTISTRY
Dental College
Year of Graduation
Number of Alaska Dental License and Date of Issuance
List all other states in which you are or have been licensed. Give license number, date of issuance, and expiration date.
STATE
LICENSE NUMBER
DATE OF ISSUANCE
EXPIRATION DATE
08-1486 (Rev. 02/01)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mf 203 - Application Form For License As A Retail Motor Fuel Dealer - Ohio Department Of Taxation
Financial
Form Psg-690-001 - Application For Licensure As A Private Security Guard Company/principal Form
Legal
Application For Licensure As A Registered Nurse By Reciprocity Information And Instructions
Business
Form Bb-692-002 - Application For Licensure As A Bail Bond Agency Or Bail Bond Agency Branch Office 1999
Legal
Related Categories
Parent category: Legal