57 Merrion Square, Dublin 2. Telephone (01) 6762069, 6762226
Registration Details Registration No
I hereby apply to be registered in the Register of Dentists for Ireland under the provisions of Section 27 of the Dentists Act, 1985.
1. Applicant’s name in full ___________________________________________________
2. Address for inclusion in the Register
Nationality _______________________ Date of Birth _____________________
Qualification held by the applicant which confers entitlement to registration in the Register.
Granting Authority/ ________________________________________________
Full Name and Address of Practice/Employer
(Name of applicant)
(a) I wish to state that to the best of my knowledge this applicant is of good character and fit for registration in the Register of Dentists.
(b) the Council should be aware of the following details of the character of this applicant which might affect his/her suitability for registration in the Register of Dentists.
Signed: _____________________ Position: __________________________
6. Declaration by applicant:
I declare that the foregoing particulars are correct and that I have not been previously registered in the Register of Dentists.
Signed: ___________________________ Date: ______________________