English to Portuguese Medical Medical: Dentistry documento de odontologia

Certificate of
Standing
1
To the certifying authority or regulator:
The dentist requesting completion of this form is an Applicant for registration/licensure in Ontario (receiving
jurisdiction) and has agreed to disclosure. This completed form bearing the signature and seal of the certifying
authority in the originating jurisdiction may be sent with any attachments directly to the above address.
The certifying authority’s (originating jurisdiction) records indicate the following information concerning:
Name: (Applicant)
(First name) (Last name)
Licence/Registration number:
Current professional address:
(As recorded on the Register/Roll)
Phone number:
(As recorded on the Register/Roll)
1. LICENCE/MEMBERSHIP
a) The Applicant
(i) has been registered/licensed in
(certifying authority’s jurisdiction)
from (M/D/Y) to (current or M/D/Y)
(ii) If the Applicant ceased to be a registered/licensed member, it was for the following reason(s):
b) The Applicant currently holds or previously held in
(certifying authority’s jurisdiction)
(i)a General Certificate/Licence from to .
(M/D/Y) (current or M/D/Y)
(ii) a Specialty Certificate/Licence in from to .
(specify specialty) (current or M/D/Y)
(iii) an Education Certificate/Licence (Residency/Internship) from to .
(current or M/D/Y)
(iv) a Graduate Certificate/Licence (Student) from to .
(current or M/D/Y)
(v) an Academic Certificate/Licence (Professor) from to .
(current or M/D/Y)
(vi) other: from to .
(M/D/Y) (current or M/D/Y)
Please complete this form and return it to:
Royal College of Dental Surgeons of Ontari