2001 Capitol Avenue, Room 104 Cheyenne, WY 82002 2017 FACILITY PERMIT RENEWAL APPLICATION Please type or print neatly. Mail this completed form with the $25 renewal fee to the address above.
1. Applicant Information Last Name
First Name
WY License #
Middle Initial
DEA #
Previous Names Used
Anesthesia/Sedation Permit Expiration
2. Home Mailing Address Home Mailing Address
City
Home Phone
Cell Phone
State
Zip
State
Zip
3. Business Address Wyoming Business Name & Mailing Address
Business Phone
City
Business Fax
Type of Practice
4. List the dentists that have used this facility in prior 12 months.
5. Correspondence from Board Office I prefer to receive mail at my:
Home
Email address is:
Business
6. Warning, Agreement, Affidavit, and Signature By signing this application:
I understand that making a false statement or giving a false answer to any question on this form is a felony punishable by imprisonment for not more than two (2) years, a fine of not more than two thousand dollars ($2,000.00), or both. (W.S. § 65-303.) In signing this application, I do hereby state that I have read, understand, and agree to abide by the rules and regulations promulgated by the Board of Dental Examiners, and W.S. § 33-15-101 through 133. I also agree to adhere to the codes of ethics applicable to my profession and this application. I verify that I am the person making the foregoing statements and that they are made in good faith and are true in every respect.
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Connect more apps... Try one of the apps below to open or edit this item. 2017-18 School Renewal Plan.pdf. 2017-18 School Renewal Plan.pdf. Open. Extract.
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