Application for review and assessment prior to licensure international applicants personal information



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DENTURIST ASSOCIATION OF MANITOBA

APPLICATION FOR REVIEW AND ASSESSMENT PRIOR TO LICENSURE

INTERNATIONAL APPLICANTS
PERSONAL INFORMATION/CONTACT INFORMATION
Surname and given name(s) of candidate at birth____________________________________________________________
Surname and given name(s) of candidate if different than above________________________________________________
Year of birth________ Country of post-secondary study_____________________________________________________
Are you a Canadian citizen?______ If not, are you a landed immigrant?_________________________________________
Home address:____________________________________________________Daytime telephone no:_________________
Address of place where you principally practice your profession: _______________________________________________
___________________________________________________________________________________________________
Office telephone number: _______________ Fax number: ________________ Email:_____________________________
CURRENT/PREVIOUS JURISDICTION LICENSURE
Type of license currently held: Full/Active (no conditions from previous or current jurisdiction)

Conditional/Temporary/Provisional (please provide details):

______________________________________________________________________
List any additional educational requirements or continuing practice requirements imposed by your current regulatory body, as a condition of your licensure:_________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
TEACHING INSTITUTIONS ATTENDED:


  1. College________________________________________________________________________

(name) (place) (year completed) (diploma/

degree attained)



  1. University______________________________________________________________________

(name) (place) (year completed) (diploma/

degree attained)



NUMBER OF YEARS IN PRACTICE:________
Country/Countries of Practice_____________________________________________________________
EXPERIENCE WITH REMOVABLE PROSTHESIS:_____________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

-2-
REQUIREMENTS


It is generally recommended that international applicants attend a recognized Canadian School of Denturism; however, in extenuating circumstances, applicants who hold an international degree in Dentistry may be accepted; these candidates will be asked to take a practical examination to determine their skill level. International applicants will be assessed based on prior learning on complete and partial dentures. A $4000.00CDN Examination Fee will apply. We do not accept applicants who are educated in Dental Technology. Patients are supplied. Based on the results of the practical examination, the Admissions Committee will recommend to the Denturist Board of Manitoba if the applicant should be accepted as an Intern in the Province of Manitoba, for a period of time to be determined by the Admissions Committee. Internship is served under the direct supervision of a licensed Denturist in Manitoba.
Candidates must verify their education documents by applying to Worldwide Education Services (WES) at http://www.wes.org/application/apply_now.aspt. The cost of this evaluation is the responsibility of the candidate. Applications can either be submitted online or mail by printing out a PDF copy of the form (note: there is a $30 processing fee for paper applications). Candidates are to apply for a WES Basic Comprehensive Course by Course Evaluation and the Denturist Association of Manitoba must be selected as a recipient of a second copy of the evaluation. We will not accept evaluation reports from candidates, we will only receive reports directly from WES.
The candidate will attach the following documents:


  • A copy of the first page of passport

  • An attestation that the candidate holds a recognized diploma in accordance with the Agreement on Internal trade (Canadian Mutual Recognition Agreement Chapter 7)

  • Proof, where required by law, of the candidate’s knowledge of the official language (via TOEFL on-line English assessment test and/or in-person interview)

  • Annex “A” duly completed

  • Authorization for collection of information

  • Letter from current regulatory body confirming membership status, license class (if applicable) and attesting the applicant is a member in good standing.

  • A cheque covering fees for opening the file ($250.00 CDN)

Contact the Admissions Chair in the event you can not produce documents listed above. In lieu of documents that are unavailable for submission (i.e. loss, translation not available), the Admissions Chair may verbally question and assess the applicant.


Registration decisions will usually be made within 5 days. More complex decisions might require more time.
Dependent on the results of the prior learning assessment, education level, skills, training, practical examination, or the information provided in Annex A herein, the Admissions Committee may choose to not recommend to the Board of Directors that an applicant be approved for licensure or internship. If the decision of the Admissions Committee is in dispute, the applicant may submit a Request for Appeal, in writing, within 30 days, to the Internal Review-Audit Committee of the Denturist Association of Manitoba. Procedures for appeals are available by contacting the association office.
Applicants may also request, in writing, that the Admissions Committee release any and all records relating to the original application that are in its custody or under its control, excepting in circumstances outlined in the Fair Registration Practices in Regulated Professions Act Section 10 (2). Reasonable cost recovery may be assessed, depending on any regulations to the Act.
Current Registration and Internship Fees

Intern fees (non-prorated) are $200.00 per annum. Professional fees for licensed denturists (non-prorated) are approximately $3300.00 per annum, plus applicable tax, plus mandatory malpractice insurance (currently $165.00 per annum).




ANNEX A

DISCIPLINARY DECISIONS


  1. Are you or have you ever been a member of another professional governing body other than denturism?

Yes No

If yes, specify:

Board:_________________________________________________________________________

License number:_________________________________________________________________

Issue Date: _____________________________ Expiration:______________________________

year/month/day year/month/day


Have you ever been the subject of a disciplinary action from this board?

Yes No

If yes, specify:

Date of decision:_________________________________________________________________

Nature of infraction:______________________________________________________________

Nature of sanction:_______________________________________________________________




  1. Are you currently practising or have you ever practised denturism in another province, Canadian territory or foreign country?

Yes No

If yes, specify:

Province, territory or country:_______________________________________________________

Name of the organization you were a member of:_______________________________________

_______________________________________________________________________________

License number:_________________________________________________________________

Issue Date:_____________________________ Expiration:______________________________

year/month/day year/month/day


Have you ever been subject of a disciplinary action from this organization (or any other jurisdiction)?
Yes No

If yes, specify:

Date of decision:_________________________________________________________________

Nature of infraction:______________________________________________________________

Nature of sanction:_______________________________________________________________

CRIMINAL OFFENCES


  1. Have you ever been convicted of a criminal infraction by a Canadian court? (Answer no if you have received a pardon for this infraction). Highway Traffic Act offenses are not Criminal Offences.

 Yes  No

If yes, specify:

Date of judgement:_______________________________________________________________

Nature of infraction:______________________________________________________________

Sentence:_______________________________________________________________________

File number:_____________________________ Court:________________________________

Province:________________________________





  1. Have you ever been convicted of a criminal infraction by a foreign court? (Answer no if you have received a pardon for this infraction).

 Yes No

If yes, specify/elaborate:___________________________________________________________

Date of judgement:_______________________________________________________________

Nature of infraction:______________________________________________________________

Sentence:_______________________________________________________________________

Place:_________________________________ Court:________________________________
Signed:__________________________________ Date:_________________________________

Candidate


3. Are there currently any criminal charges pending against you?
_ Yes _ No
If yes, specify/elaborate:___________________________________________________________

Date of charges:__________________________________________________________________

Nature of charges:________________________________________________________________

Estimated trial date:_______________________________________________________________

Place of expected trial:______________________ Court: ________________________________
Signed:___________________________________ Date:________________________________

Candidate


RETURN TO DENTURIST BOARD OF MANITOBA

PO Box 69012

RPO Tuxedo Park

Winnipeg MB R3P 2G9


AUTHORIZATION


DENTURIST BOARD OF MANITOBA
Complete the top section of form and mail to the Board of each province or state in which you are now or have been licensed to practice. If needed, you may make duplicates of this form.
Secretary: I am applying for licensure to practice denturism in the Province of Manitoba. The Denturist Board of Manitoba requires that you complete this form in order that I may be considered for licensure
This is my authorization to release any information in your files favorable or otherwise, to the Denturist Board of Manitoba

___________________________________ __________________________________

Name Signature
____________________________________

License #


______________________________________________________________________________

Address


Return to Denturist Board of Manitoba, PO Box 69012, RPO Tuxedo Park, Winnipeg MB R3P 2G9
I,___________________________ Registrar of ________________________________________

(name) (Board)


hereby certify that _____________________________________________ was granted certificate

(candidate)


number_____________________ dated____________________________ to practice denturism.
STATUS OF LICENCE:  current  expired date expired:____________________
Reason for expiration:_____________________________________________________________
LEGAL/DISCIPLINARY ACTION:  Yes  No

If yes, please explain______________________________________________________________


_________________________________ ____________________________________

Signed Date



FOR OFFICE USE ONLY File No.________
Applicant’s Name_____________________________________ Date Fee Rec’d____________

YYYYMMDD


Initial Contact Method (Email, phone, fax, mail):__________ Initial Contact Date___________

YYYYMMDD


Has this applicant previously applied for licensure? YES NO
Date Application Received______________ Date all documentation received_______________

YYYYMMDD YYYYMMDD


Original Documentation Provided? YES NO
Most current profession (dental technician, dentist, other):_______________________________
English Language Proficiency: MET NOT MET PARTIAL

Recommendation:______________________________________________________________


Date English Language Proficiency Completed: ___________________

YYYYMMDD


Assessment Decision (All Requirements Met; Some Requirements Met; Applicant Not Suitable:______
__________________ Status after Assessment: (Active; Restricted; Intern; Denied)___________
Details of Restrictions/Recommendations, if any:______________________________________

Deadline for con-ed/upgrades:______________________________________________________


Decision Date: ________________ Date Applicant Notified: _________________________

YYYYMMDD YYYYMMDD


Licensure/Internship Start Date:_____________ MB Blue Cross Unique ID#________________

(i.e. payment received) YYYYMMDD


APPEALS RECORD
Date Appeal Received:____________ Type:_____________

YYYYMMDD
Reason:_______________________________________________________________________


Number of previous appeals by this applicant:________
Appeal Hearing Date:__________________ Outcome:_________________________________

YYYYMMDD



Appeal Fee Paid: ____________ Date Notification Sent:____________

YYYYMMDD


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