WPC( =!?+W"CJGܐ(_dWRк%ͽ38r禨~"=3uA.B 9D`-8I '=U#1?1r`\j9ycھЩ Y2 {\c4YY0xKkL&e'/du q'6F7#0ʥ?+2>\Y&4@JwUz9: }Ș9ȝ9FL5DEgr GvndԷCi< GAM^CyV1(R?էl.35w*Zj"?r;j,t~%6o5c ܭu,: 8xN53v]~ZWzmSݞoXR2bm[5w3H< 2Y4D5U >$ 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$' 72'^ 'w'4'' m'\  `&Times New Roman' Application for Dental Hygiene Light Activated Bleaching Certificate  Tony Agnone 0Tony Agnone .   2P+M 0_level1  , 8.4 <DL!823  ..  5+ 4 <DL!5  2M+M 0_level2  X 5+4 44 <DL!523  ..  5+ 4 <DL!5  2M+M 0_level3   5+` ` ` <DL!523  ..  5+ 4 <DL!5  2J+M 0_level4   2( <DL!223  ..  5+ 4 <DL!5  2J+M 0_level5   2( <DL!223  ..  5+ 4 <DL!5  2G+M 0_level6   /% <DL!/23  ..  5+ 4 <DL!5  2G+M 0_level7  4 /% <DL!/23  ..  5+ 4 <DL!5  2D+M 0_level8  ` ,"< <<DL!,23  ..  5+ 4 <DL!5  2D+M 0_level9   ,"h hhDL!,23  ..  5+ 4 <DL!5  2PM 0_levsl1  , 8.4 <DL!823  Ԁ  5+ 4 <DL!5  2MM 0_levsl2  X 5+4 44 <DL!523  Ԁ  5+ 4 <DL!5  2MM 0_levsl3   5+` ` ` <DL!523  Ԁ  5+ 4 <DL!5  2JM 0_levsl4   2( <DL!223  Ԁ  5+ 4 <DL!5  2JM 0_levsl5   2( <DL!223  Ԁ  5+ 4 <DL!5  2GM 0_levsl6   /% <DL!/23  Ԁ  5+ 4 <DL!5  2GM 0_levsl7  4 /% <DL!/23  Ԁ  5+ 4 <DL!5  2DM 0_levsl8  ` ,"< <<DL!,23  Ԁ  5+ 4 <DL!5  2DM 0_levsl9   ,"h hhDL!,23  Ԁ  5+ 4 <DL!5  2PM 0_levnl1  , 8.4 <DL!823   5+ 4 <DL!5  2MM 0_levnl2  X 5+4 44 <DL!523   5+ 4 <DL!5  2MM 0_levnl3   5+` ` ` <DL!523   5+ 4 <DL!5  2JM 0_levnl4   2( <DL!223   5+ 4 <DL!5  2JM 0_levnl5   2( <DL!223   5+ 4 <DL!5  2GM 0_levnl6   /% <DL!/23   5+ 4 <DL!5  2GM 0_levnl7  4 /% <DL!/23   5+ 4 <DL!5  2DM 0_levnl8  ` ,"< <<DL!,23   5+ 4 <DL!5  2DM 0_levnl9   ,"h hhDL!,23   5+ 4 <DL!5  <:Default ParaXXX.cw ,Title? %2A`Arial?    XXXS\  `&Times New RomanS%2A`Arial64Hyperlink     35;AGMSY_11)a.i.1.a.i.1.a." i.http://www.wvdentalboard.org#|x(O$($..      )XXX)XXXX)XBMP10(9 Z6Times New Roman Regular)X3#37=CIQYag1.a.i.(1)(a)(i)1)a).i)R5 -_4+00U '!..      )XXX)XXXX)X  _       CIXX 0=CI      ApplicationforDentalHygieneLightActivatedB݌  Ќ   XBXX 0=XXX XBX  CIXX 0=CI      BleachingCertificatez݌   Ќ   XBXX 0=XXX XBX  CIXX 0=CI    1  1݌̌   XBXX 0=XXX XBX  CIXX 0=CIApplicantsName:____________________________________ 0 Address:_______________________________________________  < _______________________________________________________  H PhoneNumber:___________________________  T DentalHygieneLicenseNumber:_______________  `  " (03.""  ,B.4 <DL!XB  X,E(4 4 <DL!4X!EP2  1  )3   4   Two(2)hoursofdidacticinstructionwhichincludesavideoor (x  demonstrationofbleachingtechniquesandisolation.P.݌ 4  Ќ X! X44X!!   X?+4 44 <DL!X?CourseTitleanddate:________________________________ L  Location:_______________________________________ X Hours:__________ d Instructor:_______________________________ p InstructorsSignature:_________________________  Date:_____________   XE+ 4 <DL!444X!E""  ,E.4 <DL!X!E  X,E(4 4 <DL!4X!E 2  2  )3   4   Uponcompletionofthecourse,theapplicantmustpassa  writtenexaminationwithaminimumscoreofseventyfive  (75%). t ݌  Ќ X$ X!44X!$   , ,E.4 <DL!X!E   WrittenScore:____________ ,  , X,H+4 44 <DL!4X!HInstructorsSignature:_________________________________ 8 Date:______________  D ""  ,XH.4 <DL!444X!H  X,E(4 4 <DL!4X!Eh2  3  )3   4   Thecoursecontentmustinclude,butnotlimitedtothesubjects  #\ listedinthebleachingcourserequirementsdocumentavailable $h fromtheWestVirginiaBoardofDentalExaminersofficeoron $%t  thewebsite4$  &O  5  !  www.wvdentalboard.org!'  6&'  7 .hL݌ 0&!  Ќ XX'444X!44X!'   ,XH.4 <DL!444X!H X,H+4 44 <DL!4X!HAcoursesyllabusmustbesubmittedwiththeapplicationto H(#" determineifthisrequirementhasbeensatisfied. T)$#  XBXX 0=XXX XBX XE+ 4 <DL!444X!EXX WVBoardofDentalExaminers l+&% POBox1447 e,'& CrabOrchard,WV258270  0!!0D!!ApplicationFee:$25.00 #XX#