Last name *
First name *
College number
Email *
Phone number *
Employer/Clinic name *
Employer/Clinic phone number *
Denturist Educational School/Institute * NAIT George Brown College Vancouver Community College Other
Other school/institute
I currently have Professional Liability Insurance at the amount required by Council. ----- Yes No
Have you ever been convicted of, or been the subject of, a criminal offence or any offence related to the practice of the profession? * ----- Yes No
Has there ever been a judgement in a civil action against you with respect to your practice? * ----- Yes No
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? * ----- Yes No
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? * ----- Yes No
Has there ever been any conditions imposed upon your practice permit by this College, or any College in Alberta or any other jurisdiction? * ----- 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 understand that I may be required to submit further information to determine eligibility for registration. * ----- Yes No
Do you give permission for this College to contact any authority or organization in any jurisdiction to verify the above declarations? * ----- 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 be convicted of an offense in Alberta or any other jurisdiction. * ----- Yes No
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. * ----- Yes No
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. * ----- Yes No
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. * ----- Yes No
I confirm that I will submit my original criminal record check to the College and understand that my application cannot be processed without it. * ----- 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 registration as a denturist in Alberta. * ----- Yes No
