FOR
OFFICE USE ONLY
Let.
of Rec.
Let.
of Cert.
FEES
WEST
VIRGINIA BOARD OF DENTAL EXAMINERS
APPLICATION
FOR EXAMINATION
In compliance with
Chapter 30, Article 4, Code of West Virginia 1931, as amended, I hereby make
application to be examined for licensure as a specialist in by the State of West Virginia.
NAME
(LAST) (FIRST) (MIDDLE)
Name desired on Certificate
Present Address
(STREET) (CITY) (COUNTY) (STATE) (ZIP)
(All correspondence will be mailed to the
above address, unless the Board is otherwise notified.)
PERMANENT ADDRESS
Date of Birth Place of Birth
Social Security Number - -
I am a citizen of the United States of America by: Birth Naturalization (Give Date)
If not a citizen of the United States state
declaration of intention to become citizen and show progress toward becoming a
citizen of the United States.
Height Weight
lbs. Complexion Race
Sex Color of Hair Color of Eyes
I am (check one) Married Single Divorced
Name of Spouse (if married)
If Married, maiden name (if applicable)
Pre-dental Education:
Date of graduation from and name of high
school or preparatory schools.
Colleges attended and degrees earned (state
inclusive dates of attendance)
Dental Education:
Dental Schools attended and degrees earned
(state inclusive dates of attendance)
Graduate work of internship (Give dates)
License
held in other states past and present and dates issued.
Application for license refused - - explain
and give details
I belong to the following professional
societies and organizations:
If I am licensed to practice dentistry in West Virginia, I plan to (open my own office, intern at
, enter the armed forces, join Dr. , etc.):
in West Virginia starting
I offer the following references of good
moral character, neither of whom is related to me or is a teacher at any dental
college I attended, who shall write letters, directly to the secretary of the
Board concerning the applicant. (If
possible have dentists practicing in the State of West Virginia.)
Name Name
Address Address
Occupation Occupation
Physician=s Statement of
Examination of Applicant
I, ,
a duly licensed physician of
the State of , have this day examined
The applicant herein, and my medical
examination reveals that such applicant is free from all infectious,
malignant, and contagious diseases, and such
applicant is in sound and good health.
Examination made
in ,
State of
, on the day of , A. D. 20 .
,
M. D.
For the past ten
years, my addresses and occupations have been:
(Please fill in this section, whether or not you were employed.)
Dates Addresses Occupation
I have never been charged with, or convicted
of a crime of the grade of felony except:
I have never been charged with, or convicted
of, or been a party to a violation of the dental laws of this or any other
jurisdiction except as follows:
Father=s Name Mother=s Name
Address Address
Occupation Occupation
Has your surname ever been changed? If so, when and from what?
In addition to the foregoing information, I
add the following:
1.
I will read the Dental
Laws of West Virginia before appearing for examination and I intend to practice
Dentistry in keeping with the spirit and the letter of these laws.
2.
I hereby give my
permission for the West Virginia Board of Dental Examiners to secure additional
information concerning me or any of the statements in this application from any
person or any source the Board may desire.
3.
I further agree to
submit to questioning by the Board or any member thereof, and to substantiate
my statements when necessary.
4.
I shall present my
diploma from the dental school granting my degree at the time set for the
examination, if required or requested by the Board. At the same time, I shall present all other credentials required
or requested by the Board.
5.
I am enclosing a postal
money order or a check in the amount of $300.00 to cover this application
fee. I understand that this fee is not
refundable.
The
above statements are true in every particular.
Signature
State
of
County
of
Personally appeared
(Name
of Applicant)
and
made oath that the foregoing statements subscribed to by him/her are true.
Notary
(SEAL)
My
commission expires on the day of , 20 .
THE
STATE OF
COUNTY
OF Affix
PHOTOGRAPH
Before me, a Notary
Public in and for said State and County, on
No caps or hats
this day personally
appeared please
and
did in my presence sign the foregoing application and acknowledged
to
me that all statements, facts, and answers contained in this application
are
true and correct; and that the applicant executed this application for
the
purposes and consideration therein expressed.
I also certify that the photograph attached hereto is
a likeness of
the
applicant.
Witness my hand and seal of office on this the day of , A. D. 20 .
Signature of Notary Public
Name of Notary Public typed
(SEAL) Notary
Public in and for the County of
State of
My Commission expires
CERTIFICATION
OF SPECIALTY
I, ,
Dean of have
read this application of the above applicant for examination before the West
Virginia Board of Dental Examiners, and I certify such applicant to the West
Virginia Board of Dental Examiners as a graduate of this college; and I further
state that the degree of was conferred on such applicant on the day of , A. D. 20 .
Witness my hand as Dean of the above stated college or
university, and the seal of such institution.
Dean
(Seal
of College or University
Conferring
Dental Degree)
Please make all check and money orders payable to AWest Virginia Board of Dental Examiners@.
WV Board of Dental Examiners
1319 Robert C. Byrd Drive
PO Box 1447
Crab Orchard, WV 25827