EFTA01197066.pdf

CI P b'::SIVET C`ASPAEQ GEW...."1.1"; R4O5. Etle.,PC BRO.:" ..02 Dental Board of California DEPARTMENT Or CONSUMER AFFAIRS Application for Issuance of License Number and Registration of Place of Practice* Business & Professions Code §§ 1650 OFFICE USE ONLY OFFICE USE ONLY ATS # Rec # Date Application Received Fee Paid Date cashiered Complete this form to obtain your license. Please print legibly. Date License mailed License # Name Last First Middle Address of Record (will be public information) Street and Number City State Zip Code Address of Practice, if different Street and Number City State ZIP Code *Note: If you do not yet have a practice address in California, you may leave this section blank. However, if and when you do have a practice address in California, you must report it to the Board immediately. Telephone number ( Email address (optional) Applicant's File Number issued by Dental Board of California Certification I certifi under penalty of perjury under the laws of the Stale of California that the information I provide d to the Board in this application is true and correct. Date Signature of Applicant The information requested herein is mandator), unless designated as optional and is maintained by Dental Board of California, 2005 Evergreen Street, Suite 1550, Sacramento. CA 95815, Executive Officer, 916-263-2300, in accordance with Business & Professions Code, §1600 et seq. The information requested will he used to determine eligibility. Failure to provide all or any part of the requested information will result in the rejection of the application as incomplete. Each individual has the right to review the personal informat ion maintained by the agency unless the records are exempt from disclosure. Applicants are advised that the names(si and addresstes) submitted may. under limited circumstances. he made public. Rev(11/07) EFTA01197066