Free 50326.FH11 - Indiana

APPLICATION FOR APPROVAL OF A STUDY CLUB TO PROVIDE CONTINUING EDUCATION COURSES FOR DENTISTS AND DENTAL HYGIENISTS
State Form 50326 (R2 / 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 W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2057 E-mail: [email protected]

INSTRUCTIONS: Please type or print legibly.

FOR OFFICE USE ONLY
Date of review (month, day, year) Application fee Decision Date fee paid (month, day, year) Receipt number Initials

DO NOT WRITE ABOVE THIS LINE
Type of application New Application Renewal The study club will provide courses for: Dentists Dental Hygienists YOU MUST INCLUDE A COPY OF THE STUDY CLUBS BY-LAWS WITH THIS APPLICATION Name of study club Address of study club (number and street, city, state, and ZIP code) CONTACT PERSON: Name Address (number and street, city, state, and ZIP code) Daytime telephone number E-mail address

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NAMES AND ADDRESSES OF EACH OFFICER: PRESIDENT: Name Address (number and street, city, state, and ZIP code) License number Daytime telephone number

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VICE-PRESIDENT: Name Address (number and street, city, state, and ZIP code) License number Daytime telephone number

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SECRETARY: Name Address (number and street, city, state, and ZIP code) License number Daytime telephone number

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OTHER (Please specify): Name Address (number and street, city, state, and ZIP code) License number NAMES OF AT LEAST FIVE MEMBERS OF THE STUDY CLUB: 1. 2. 3. 4. 5. PLEASE ANSWER THE FOLLOWING: 1. For what purpose was the study club organized? Daytime telephone number

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2. Does the study club operate under the direction of elected officers? Yes No 4. Will the study club maintain written attendance records of all meetings? Yes No

3. Will the study club conduct regular meetings? Yes No

SIGNATURE OF AUTHORIZED INDIVIDUAL I hereby swear or affirm, under the penalties of perjury, that the statements made in this application are true, complete and correct.
Printed name of authorized individual Title 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 named study club requested by the Agency, or the Board or any of their authorized representatives in connection with processing this application for approval of a study club 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 or faxed 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.