Last name * First name * Registration number * Email * Phone number * Registration Change Reason for change * ----- Parental leave Change of jurisdiction Other Effective date * Declarations
You may be contacted by the College for further information.
I understand that I must hold a provisional or general practice permit with the College in order to practice the profession of denturism in Alberta. * ----- Yes No I understand that the practice of denturism is not restricted to only providing direct patient services, but also includes the design, construction, repair, alteration and fitting of any complete or partial denture for the purpose of restoring and maintaining function and appearance; teaching, managing or conducting research in the science, techniques and practice of denturism; or providing restricted activities authorized by the Denturists Profession Regulation. * ----- Yes No I understand that I may not use the protected titles of denturist or registered denturist once I am no longer regulated by the College. * ----- Yes No I acknowledge that I am responsible for compliance with the Continuing Competence Program for the time that I was a regulated member with the College of Alberta Denturists. * ----- Yes No I understand that the qualifications for eligibility for registration as a regulated member may change in the future without notice. * ----- Yes No I understand that it is unlawful to practice denturism in Alberta without being registered with the College of Alberta Denturists and that penalties may be enforced, as per the Health Professions Act, should I act unlawfully in this manner. * ----- Yes No I understand that as per section 48(1) of the Health Professions Act, a person who meets the requirements of s. 46(1) [mandatory registration] and does not comply with a request to register with the College under s. 46(2) is guilty of an offense. * ----- Yes No I understand that for two years, following my change to unregulated status, a complaint may be lodged against me through the legislated complaint process. * ----- Yes No I understand that the collection, use and disclosure of my personal information will be handled in accordance with applicable privacy policies and laws. * ----- Yes No I will immediately advise the College, in writing, if there is any change to any of the information contained in this application. * ----- Yes No I will immediately advise the College, in writing, should I wish to return to practice. * ----- Yes No I verify that all information contained in this application, including these declarations, is complete and accurate. I understand that a false or misleading statement, an omission or misrepresentation may have impact on my future registration as a denturist in Alberta. * ----- Yes No