Archived Form

First Name: *
Last Name: *
License Number: *
Renewal Option: *
Full Practice - Renewal
Full Year Non-Practice - Renewal
Payment Options: *
Credit Card
E-Transfer
Cheque
Are you currently the subject of any investigations, review, disciplinary hearings or proceedings (subject to the profession of Dental Assisting) in any province, territory, state, country or elsewhere?: *
If yes, please explain:
Has any registration, certificate, diploma and/or license entitling you to practice dental assisting in any province, territory, state, country, or elsewhere ever been denied, issued with undertakings, restricted, suspended or cancelled?: *
If yes, please explain:
Have you ever had a finding in the nature of professional misconduct, unskilled practice, incompetence or incapacity or a like finding, made against you in any province, territory, state, country or elsewhere as a dental assistant or in any health profession other than dental assisting?: *
If yes, please explain:
Signature of Applicant: *