•
TAT
•
0~
CALlfl'DRNIA
c:::1
c:::
a
OtPARTMtNT
OF
CONSUMtR AFFAIRS
• •
If you were employed at numerous locations during the time period
being documented, reproduce this form before you proceed.
CERTIFICATION OF THE CLINICAL PRACTICE OF DENTISTRY
This Certification is for use in establishing eligibility to become licensed in California based upon credentials
and must accompany the Application to Establish Eligibility for Licensure by Credential.
The undersigned certifies that
(Full name of applicant)
practiced
clinical dentistry in the State of during the inclusive dates below:
From (M/D/Y) To (M/D/Y) Total Number of Hours per Year
Is this employment self-employment?
Yes No
If this is self-employment, complete the certi
fication below and attach a copy of page 1 only, of
Sched
ule C Form 1040, for each year of qualifying practice time. Or, if incorporated, send page 1 only, of
Form 1120S. If you were not self-employed, the custodian of records must sign the certification below.
Practice address during the period indicated above (include city/state/zip):
Business name and address, if different from the practic
e address.
Employer/Custodian of Records:
I certify under penalty of perjury under the laws of the State of California that I am custodian of
records of the business listed above, and that the above and any attachments hereto are a true and
correct representation of the records of the business.
Printed/Typed Name of Person Certifying Signature of Person Certifying
Date of Signing Telephone number FAX
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
DENTAL BOARD OF CALIFORNIA
2005 Evergreen St., Suite 1550, Sacramento, CA 95815
P (916) 263-2300 | F (916) 263-2140 | www.dbc.ca.gov
. I
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
