Reinstatement

Last name *

First name *

Registration number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone number *

Employment Information

Employer/Clinic name

Employer/Clinic phone number

Employer/Clinic address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Expected start date

English Language Proficiency

English is my primary language for speaking, reading and writing.

My primary language is (please indicate below)

Professional Liability Insurance

I currently have Professional Liability Insurance at the amount required by Council.

Criminal Record Check

You must submit a current Criminal Record Check with Category A Vulnerable Sector Search. This must be completed within the last 6 months.The original document must be provided to the College.

Acknowledgement

I will supply the College with a current Criminal Record Check with Category A Vulnerable Sector Search

Declarations

You may be contacted by the College for further information.

Have you ever been convicted of, or been the subject of, a criminal offence or any offence related to the practice of the profession? *

Has there ever been a judgement in a civil action against you with respect to your practice? *

Are you currently or have you previously been investigated by this College or any other regulatory body within Alberta or in another jurisdiction involving an allegation of unprofessional conduct? *

Have you ever been the subject of a finding of unprofessional conduct by this College or any other regulatory body within Alberta or in another jurisdiction? *

Has there ever been any conditions imposed upon your practice permit by this College, or any College in Alberta or any other jurisdiction? *

I understand that the collection, use and disclosure of my personal information will be handled in accordance with applicable privacy policies and laws. *

I understand that I may be required to submit further information to determine eligibility for registration. *

Do you give permission for this College to contact any authority or organization in any jurisdiction to verify the above declarations? *

I will immediately advise the College, in writing, if there is any change to any of the information contained in this application. *

I will immediately advise the College, in writing, should I be convicted of an offense in Alberta or any other jurisdiction. *

I will immediately advise the College, in writing, should I become the subject of a finding of or proceeding related to allegations of unprofessional conduct in Alberta or any other jurisdiction. *

I will immediately advise the College, in writing, should I be denied registration with any regulatory body in Alberta or any other jurisdiction within the profession of denturism or any other profession. *

I will immediately advise the College, in writing, should my practice permit be suspended, cancelled or equivalent with any regulatory body in Alberta or any other jurisdiction within the profession of denturism or any other profession. *

I confirm that I will submit my original criminal record check to the College and understand that my application cannot be processed without it. *

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 registration as a denturist in Alberta. *

Employment Information

English Language Proficiency

Professional Liability Insurance

Criminal Record Check

Other Required Documentation

Declarations