Licence Renewal Form

LICENCE REINSTATEMENT FORM Saskatchewan Dental Assistants' Association PO Box 294 Kenaston SK S0G 2N0 Phone 306-252-2769 Fax 306-252-2089
On-Line Banking Payment Instructions: Enter your financial institution website and log into your account. Select the payment screen and "add a payee". Search for "Saskatchewan Dental Assistants Association, note the name may be appreviated depending on the banks parameters. Ex. Saskatchewan Dental Assistants Assoc		Financial Institutions available for online Payments: Credit Unions, Bank of Montreal, Canadian Imperial Bank of Commerce, Scotia Bank and TELPAY. (Note: TD & Royal not available)

Name Sk Registration #
Address
City: Prov: PC:
Telephone (Res): Telephone (Wk): Cell:
Employer's Name Employment Community
E-mail Address: (mandatory)
Reinstatementl:		Health District (required in in-province applicants):
	Full Practising $250.00 Restricted Practising $250.00 After June 15 - $165.00	Athabasca Cypress Five Hills Heartland Keewatin Yatthe Kelsey Trail Mamawetan Churchill River Prairie North Prince Albert Parkland Regina Qu'Appelle Saskatoon Sun Country Sunrise
	Note: Contact the SDAA office regarding the rules related to "Non Practice" status
Employment Status:
	Full time as DA Part time as DA Casual as DA Not employed in Dentistry Employed as DT/DH Student
Declaration: Are you currently the subject of any investigations, review, disciplinary hearings or proceedings (subject to the dental profession) in any province, territory or other jurisdiction? No Yes If yes, please explain...... : Late Fees: After January 31 lapsed members must hold their NDAEB Certificate and pay an additional reinstatement fee. The reinstatement fee is calculated into the total as listed.
Additional Comments: