Nomination Petition Form For Dentists 2016 Maryland State Board of Dental Examiners



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Nomination Petition Form For Dentists - 2016

Maryland State Board of Dental Examiners
To Be Completed by Dentists
Do not use this form if you are a State Dental Organization Affiliated with A National Organization or a dentist who is nominated by a State Dental Organization Affiliated with a National Organization
This form must be completed and returned to the Board on or before April 11, 2016
Return this form to: Murray Sherman, Legal Assistant, Maryland State Board of Dental Examiners, Spring Grove Hospital Center, Benjamin Rush Building, 55 Wade Avenue, Catonsville, Maryland 21228.
Use this form to nominate a dentist for membership on the Maryland State Board of Dental Examiners. A nominee must meet the qualifications for membership contained in the Annotated Code of Maryland, Health Occupations Article, § 4-202 (c). Note that each candidate must obtain the signatures of 10 dentists who support the nomination. A dentist may be both a petitioner and a nominee. A dentist who is a petitioner but not a nominee is counted as one of the 10 dentists who support the nomination. A dentist who is a petitioner and a nominee is not counted as one of the dentists who support the nomination.
A petitioner must hold a Maryland general license to practice dentistry, a limited license to practice dentistry, a teacher’s license to practice dentistry, a retired volunteer license to practice dentistry, or a volunteer license to practice dentistry. A dentist on inactive status may not be a petitioner.
The law requires the signatures of 10 dentists who support the nomination. However, this form allows for the signatures of 12 dentists, in the event that one or two petitioners do not qualify. If you choose, you may provide the signatures of only 10 dentists who you believe qualify. Note however that if fewer than 10 dentists qualify, this form will be invalid.
Nominees must also submit their curriculum vitae along with this form.
An incomplete form will be returned. A form received after April 11, 2016 will be invalid regardless of the date of postmark.
You will receive a confirmation letter from the Board shortly after the Board receives this form. Nevertheless, you are strongly urged to contact Murray Sherman at 410-402-8530 to confirm the Board’s receipt of this form.

Nominee
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number
________________________________________________________________________

Signature


By signing this Nomination Petition Form For Dentists I agree to be nominated as a candidate for appointment to the Maryland State Board of Dental Examiners
________________________________________________________________________

Print Address on File with the Board

Petitioner
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(1) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board


(2) Dentist In Support of Nomination


________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature

________________________________________________________________________

Print Address on File with the Board

(3) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(4) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(5) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board


(6) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(7) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(8) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(9) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(10) Dentist In Support of Nomination

(Must be completed if the petitioner and nominee is the same individual)


________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(11) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board

(12) Dentist In Support of Nomination
________________________________________________________________________

Print Name as it Appears on Maryland Dental License / Provide License Number


________________________________________________________________________

Signature


________________________________________________________________________

Print Address on File with the Board






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