Register of Dentists Application Form 57 merrion square



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An Chomhairle Fiaclóireachta

Dental Council



Register of Dentists



Application Form


57 MERRION SQUARE


DUBLIN 2

Web Address: www.dentalcouncil.ie




DENTAL COUNCIL




AN CHOMHAIRLE FIACLÓIREACHTA

57 Merrion Square, Dublin 2. Telephone (01) 6762069, 6762226



Registration Details Registration No



(please complete in BLOCK letters) (for office use only)

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


______________________________________________________________________________
____________________________________________________________________________­__
____________________________________________________________________________­__
____________________________________________________________________________­__
Email Address __________________________________________________________________

Nationality _______________________ Date of Birth _____________________


Place of Birth _____________________

3. Qualifications

Qualification held by the applicant which confers entitlement to registration in the Register.

Qualification ________________________________________________
Granting Authority/ ________________________________________________

University


Date Granted ________________________________________________

4. Employment Record (from date of graduation up to date)
(Please format all dates as DD/MM/YY)

Date


From - To

Full Name and Address of Practice/Employer


Grade or title of


Position










5. Character Reference:

To be completed by the Head/Dean of your dental training school if applying for registration within one year of graduation:

Re:____________________________________

(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.

or

(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: __________________________


Date: _______________________

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: ______________________


It is an offence for a person to make a false declaration for the purpose of obtaining registration. Any person who furnishes or attempts to furnish fraudulent or altered documents/certificates may be prosecuted.
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