WPC( @h<"LWP3: Ŏ_-RB<8*q D:k<2hRu:;9m%p٩>.|[ )Czc0@#w"5I͒skbT)&v]ĴpJxˋCڞu$o_8Ռk_t|SO0 t(Ģ6R>Is!3XwQ_h;ZuN"S US8dR~Lu+inD#G+(S`P+`a@͌Sx`,PSΉ(j,ɢ>>c/ 6_ ] &`dC!Zl͛@QourpX @Gkt8n ``_Wj2BuWrszT*fa-U(%5U >$ 0 0 0 0 0 0 0 0t 0b 0P 08 0 0 0 0 0 0 0` 0< 0# 0 0 0 0 0 0i 0D 0n 0 U *! 0Y! 1e" 7}":"" 0N" 0####UN& %&M&(&N"' 1u$' 72'w'4'' m'^ '\  `&Times New Roman' Application for Dental Hygiene Light Activated Bleaching Certificate  Tony Agnone 0April Stone .   2P+M 0_level1  , 8.4 <DL!823  ..  5+ 4 <DL!5  2M+M 0_level2  X 5+4 44 <DL!523  ..  5+ 4 <DL!5  2M+M 0_level3   5+` ` ` <DL!523  ..  5+ 4 <DL!5  2J+M 0_level4   2( <DL!223  ..  5+ 4 <DL!5  2J+M 0_level5   2( <DL!223  ..  5+ 4 <DL!5  2G+M 0_level6   /% <DL!/23  ..  5+ 4 <DL!5  2G+M 0_level7  4 /% <DL!/23  ..  5+ 4 <DL!5  2D+M 0_level8  ` ,"< <<DL!,23  ..  5+ 4 <DL!5  2D+M 0_level9   ,"h hhDL!,23  ..  5+ 4 <DL!5  2PM 0_levsl1  , 8.4 <DL!823  Ԁ  5+ 4 <DL!5  2MM 0_levsl2  X 5+4 44 <DL!523  Ԁ  5+ 4 <DL!5  2MM 0_levsl3   5+` ` ` <DL!523  Ԁ  5+ 4 <DL!5  2JM 0_levsl4   2( <DL!223  Ԁ  5+ 4 <DL!5  2JM 0_levsl5   2( <DL!223  Ԁ  5+ 4 <DL!5  2GM 0_levsl6   /% <DL!/23  Ԁ  5+ 4 <DL!5  2GM 0_levsl7  4 /% <DL!/23  Ԁ  5+ 4 <DL!5  2DM 0_levsl8  ` ,"< <<DL!,23  Ԁ  5+ 4 <DL!5  2DM 0_levsl9   ,"h hhDL!,23  Ԁ  5+ 4 <DL!5  2PM 0_levnl1  , 8.4 <DL!823   5+ 4 <DL!5  2MM 0_levnl2  X 5+4 44 <DL!523   5+ 4 <DL!5  2MM 0_levnl3   5+` ` ` <DL!523   5+ 4 <DL!5  2JM 0_levnl4   2( <DL!223   5+ 4 <DL!5  2JM 0_levnl5   2( <DL!223   5+ 4 <DL!5  2GM 0_levnl6   /% <DL!/23   5+ 4 <DL!5  2GM 0_levnl7  4 /% <DL!/23   5+ 4 <DL!5  2DM 0_levnl8  ` ,"< <<DL!,23   5+ 4 <DL!5  2DM 0_levnl9   ,"h hhDL!,23   5+ 4 <DL!5  <:Default ParaXXX.cw ,Title? %2A`Arial?    XXXS\  `&Times New RomanS%2A`Arial64Hyperlink     35;AGMSY_11)a.i.1.a.i.1.a." i.http://www.wvdentalboard.org#|x(O$(8$..      )X%XX)XX%XX)X%BMP10(9 Z6Times New Roman Regular)X3#37=CIQYag1.a.i.(1)(a)(i)1)a).i)-_4 UqR5 '8!..      )XXX)XXXX)X  _       QUXX #QU      ApplicationforNitrousOxideMonitoringCertificateB݌  Ќ   XK\X #XXX XK\  QUXX #QU       XK\X #݌̌   XK\XX XK\XXX XK\   XK\XXX &o%X XK\ApplicantsName:____________________________________  Address:_______________________________________________ u _______________________________________________________ H PhoneNumber:___________________________  k  " (03.""  ,B.4 <DL!XB  X,E(4 4 <DL!4X!E2  1  )3   4   Two(2)hoursofdidacticinstruction.݌   Ќ X! X44X!!   X?+4 44 <DL!X?CourseTitleanddate:________________________________ g   Location:_______________________________________ :   Hours:__________  ]  Instructor:_______________________________ 0  InstructorsSignature:_________________________   Date:_____________ Y   XE+ 4 <DL!444X!E""  ,E.4 <DL!X!E  X,E(4 4 <DL!4X!E2  2  )3   4   Uponcompletionofthecourse,theapplicantmustpassawrittenexamination O withaminimumscoreofseventyfive(75%). ݌ " Ќ X$ X!44X!$   , ,E.4 <DL!X!E  WrittenScore:____________ x  , X,H+4 44 <DL!4X!HInstructorsSignature:_________________________________ K Date:______________ n ""  ,XH.4 <DL!444X!H  X,E(4 4 <DL!4X!E 2  3  )3   4   Thecoursecontentmustinclude,butnotlimitedtothesubjectslistedinthe  nitrousoxidemonitoringrequirementsdocumentavailablefromtheWestVirginia  BoardofDentalExaminersofficeoronthewebsite4$ &O  5  !  www.wvdentalboard.org!;'  6&'  7 , 1. ݌ j Ќ XX'444X!44X!'   ,XH.4 <DL!444X!H& %% &o""  ,,K.4 <DL!4X!K  X,E(4 4 <DL!4X!E2  4  )3   4    &o% %&ProvideproofofcurrentcertificationinhealthcareproviderCPRthroughthe ` AmericanHeartAssociationortheAmericanRedCross(Mustattach 4 documentation)݌  Ќ ,X*4X!44X!*   K.4 <DL!4X!K X,H+4 44 <DL!4X!HAcoursesyllabusmustbesubmittedwiththeapplicationtodetermineifthis ]  requirementhasbeensatisfiedunlesspreviouslyprovidedandapprovedbythe 0 ! Board. !S" Allfourpointsofthisapplicationmustbesatisfiedbeforenitrousoxidecertificate "$ isissued.NitrousOxidemonitoringbyadentalhygienist/dentalassistantmustbe |#% delegatedbythesupervisingdentistunderdirectsupervision. O$& Completionofaboardapprovedcourseandexaminationdoesnotauthorizeyou %E!( topracticetheseprivilegesuntilyourapplicationiscompletedandacertificateis &") receivedfromtheBoardoffice '"* & %% &o XE+ 4 <DL!444X!E#XX %&O# 4 WVBoardofDentalExaminers A)$,  4 POBox1447 '*w%-  4 CrabOrchard,WV25827  +]&.  4 ApplicationFee:$25.00