Registration Form For State Dental Organizations



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Registration Form For State Dental Organizations

Affiliated With a National Organization


Maryland State Board of Dental Examiners
COMPLETE THIS FORM IF YOU ARE A STATE DENTAL ORGANIZATION AFFILIATED WITH A NATIONAL ORGANIZATION AND YOU WISH TO REGISTER WITH THE BOARD TO NOMINATE A DENTIST CANDIDATE FOR APPOINTMENT TO THE MARYLAND STATE BOARD OF DENTAL EXAMINERS
This form must be received by the Board on or before April 7, 2016
If you wish to nominate a dentist candidate you must also complete a Nomination Petition Form For State Dental Organizations Affiliated With a National Organization. The Nomination Petition Form For State Dental Organizations Affiliated with a National Organization must be filed on or before April 7, 2016 or it will be invalid. The State dental organization affiliated with a national organization must be properly registered with the Board before the Nomination Petition Form for State Dental Organizations Affiliated with a National Organization will be reviewed for filing.
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, Legal Assistant at 410-402-8530 to confirm receipt of this form.

I. General Information

Name of State dental organization affiliated with a national organization

Address of State dental organization

Telephone number of State dental organization

Contact person’s name and telephone number

Name of national dental organization with which state organization is affiliated

Address of national dental organization


________________________________________________________________________

Telephone number of national dental organization

Contact person’s name and telephone number
II. Documentation
The following documents must be provided with this registration form:
1. A current Certificate of Status issued by the State Department of Assessments and Taxation;

2. A certified copy of the State dental organization’s bylaws; and

3. Proof that the State dental organization is a constituent organization of the national organization.
III. Signature of President, Executive Director, or Administrator
I solemnly affirm under penalties of perjury and upon personal knowledge that the contents of the foregoing paper and all attachments are true.

_______________________________________________________

Signature of President, Executive Director, or Administrator

of State Dental Organization Affiliated with a National Organization


_______________________________________________________

Title (Either President, Executive Director, or Administrator)

_______________________________________________________

Date





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