D-4, r. 5 - Regulation respecting other terms and conditions for permits of the Ordre des denturologistes du Québec to be issued

Schedule Disposition versions

2012-09-01

SCHEDULE 1

(s. 4)

ORDRE DES DENTUROLOGISTES DU QUÉBEC

PERMIT APPLICATION FORM

To the board of directors of the Ordre des denturologistes du Québec:

I,__________(name)__________ domiciled at __________(number)__________ __________(street)__________ __________(municipality)__________ __________(province or country)__________, am appying for a permit.

I engage to comply with the provisions of the Act and regulations of the Ordre des denturologistes du Québec.

I declare that all the information provided in the following questionnaire is true and complete.

I authorize the Ordre des denturologistes du Québec to verify the facts stated in this permit application.

In witness thereof, I have signed at __________(place)__________ on __________(date)__________ __________(candidate)__________

Sworn before me, at ______________________________, this ______________________________ day of 20__________.

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Commissioner for oaths for

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GENERAL INFORMATION

Surname and given name(s) of candidate at birth _______________________________________________

Date of birth ___________________________ Place of birth ___________________________

Civil status: single __________________ married __________________ other __________________

Surname and given name(s) of spouse ___________________________________________________________

Are you a Canadian citizen? ____________________________________________________

If not, are you a landed immigrant? _______________________________________________________

If you are a landed immigrant, how long have you been living in Canada? _____________________________

Home address __________________________________________________________________

Home telephone No. _______________________________________________________

Address of place where you principally practise your profession*

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Office telephone No. _________________________________________________________

Teaching institutions attended:

(A) ELEMENTARY _____(name)_____ _____(place)_____ _____(year completed)_____ _____(diploma)_____

(B) SECONDARY _____(name)_____ _____(place)_____ _____(year completed)_____ _____(diploma)_____

(C) COLLEGE _____(name)_____ _____(place)_____ _____(year completed)_____ _____(diploma)_____

LANGUAGE(S) SPOKEN: French __________ English __________ Others __________(specify)__________

LANGUAGE(S) WRITTEN: French __________ English __________ Others __________(specify)__________

The candidate shall provide the following in support of his application:

( ) 2 passport photographs with his name in block letters and his signature on the reverse side;

( ) a certified extract of his act of birth;

( ) the papers prescribed in section 4 of the Regulation respecting other terms and conditions for permits of the Ordre des denturologistes du Québec to be issued (chapter D-4, r. 5).

* N.B. A denturologist who begins to practise his profession principally at another address must immediately notify the secretary of the Order; he must also notify the secretary of any change in the place where he practises his profession within 30 days of the change.

Decision 83-02-25, Sch. 1.