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__________.
Commissioner for oaths for
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*
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.