Free 50327.FH11 - Indiana

APPLICATION FOR APPROVAL OF AN INDIVIDUAL OR ORGANIZATION TO PROVIDE CONTINUING EDUCATION COURSES FOR DENTISTS AND DENTAL HYGIENISTS
State Form 50327 (R / 2-06) Approved by State Board of Accounts, 2006

RETURN THIS APPLICATION TO: INDIANA STATE BOARD OF DENTISTRY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room 072 Indianapolis, Indiana 46204 Telephone: (317) 234-2057 E-mail: [email protected]

FOR AGENCY USE ONLY:
Receipt number Date reviewed (month, day, year) Fee paid Decision: Date paid (month, day, year) Initials

PLEASE TYPE OR PRINT LEGIBLY
Name of individual or organization Applying as an: Type of application

New Application
The individual or organization will provide courses for:

Renewal Dental Hygienists

Individual
Address (number and street, city, state, and ZIP code) Daytime telephone number

Organization

Dentists

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)

E-mail address

Web address

SIGNATURE OF AUTHORIZED INDIVIDUAL
Printed name of authorized individual Title Telephone number E-mail address Fax number Signature of authorized individual Date signed (month, day, year)

(

)

(

)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency, or Indiana State Board of Dentistry, any files, documents, records or other information pertaining to the undersigned requested by the Agency, or the Board or any of their authorized representatives in connection with processing this application for approval of a individual or organization to provide continuing education courses. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency, or the Indiana State Board of Dentistry to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency, and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original. AFFIRMATION I hereby swear or affirm, that I have read the above statements and agree to same.
Printed name of authorized individual Title Signature of authorized individual Date signed (month, day, year)

NOTICE In compliance with IC 4-1-6, this agency is notifying you that you must provide the requested information or your application will not be processed. You have the right to challenge, correct, or explain information maintained by this agency. The information you provide will become public record.