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.

SIGNATURE OF APPLICANT Page 1 of 1

DATE Revised 1/2015

2017 Renewal - Facility Permit.pdf

There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. 2017 Renewal ...

41KB Sizes 4 Downloads 258 Views

Recommend Documents

2017-18 School Renewal Plan.pdf
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.

Membership Renewal Form 2017.pdf
KELAB RENANG IKAN BILIS, HONG LEONG BANK BERHAD, AC NO. 32100000386. Please indicate in Ref :Swimmer's Name 2017 Renewal and email bank ...

Renewal form 2017.pdf
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. Renewal form ...

2017-18 Facility Rental Packet.pdf
Gym‐High School Main** Per District. Regulations ... Skyridge High (1,100), Westlake High (1,150). Stage Only ... 2017-18 Facility Rental Packet.pdf. 2017-18 ...

UCO Operations 2017, FCHR Registration and Renewal, Expiration ...
Mar 5, 2017 - UCO Operations 2017, FCHR Registration and Renewal, ... tion Dates and De-listings, HOPA, March 5, 2017.pdf. UCO Operations 2017, FCHR ...

DRC 2017-18 membership and renewal form.pdf
New members - if you are also a member of another running club please state its name and. give your first and second claim preferences. If you have been a member of another running club. in the past please provide the name of the club and the date on

Facility Schedule Open Facilities for Winter Break 2017-2018.pdf ...
Page. 1. /. 1. Loading… Page 1. Facility Schedule Open Facilities for Winter Break 2017-2018.pdf. Facility Schedule Open Facilities for Winter Break 2017-2018.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Facility Schedule Open Faci

Facility Use Form updated 10 2017.pdf
FACILITY USE RULES. 1. Fees for use of school facilities must be paid when the approved facility application is received by the requester. 2. Fees must be received before the date of use or access to the building w ill not be scheduled. 3. Refunds wi

2017 Wyoming State Building Facility Condition Index.pdf ...
Page 1 of 13. Building. Number Building Agency Building. Location Building Type. Facility. Condition. Index (FCI). Facility. Condition. Needs Index. (FCNI). Gross Building SF. 3181 Stockyards - Hay Barn Livestock Board Cheyenne BARN 0.751 0.756 * 1,4

Pitt Campus Recreation Facility Hours - End of Summer 2017.pdf ...
Retrying... Pitt Campus Recreation Facility Hours - End of Summer 2017.pdf. Pitt Campus Recreation Facility Hours - End of Summer 2017.pdf. Open. Extract.

Pitt Campus Recreation Facility Hours - Spring 2017.pdf
*Facility hours are subject to change. Page 1 of 1. Pitt Campus Recreation Facility Hours - Spring 2017.pdf. Pitt Campus Recreation Facility Hours - Spring 2017.

Pitt Campus Recreation Facility Hours Winter Break 2017.pdf ...
Page 1 of 1. CAMPUS RECREATION. WINTER BREAK FACILITY HOURS. Dec. 15—Jan. 8. *AQUATICS FACILITIES. WED. DEC. 13 THURS. DEC 14 FRI. DEC. 15 DEC. 16-JAN. 7 MON. JAN. 8. BELLEFIELD POOL Open reg. hours Open reg. hours Closes at 5pm CLOSED Opens at 7am

Pitt Campus Recreation Facility Hours - Fall 2017.pdf
*Facility hours are subject to change. Page 1 of 1. Pitt Campus Recreation Facility Hours - Fall 2017.pdf. Pitt Campus Recreation Facility Hours - Fall 2017.pdf.

Pitt Campus Recreation Facility Hours Winter Break 2017.pdf ...
Page. 1. /. 1. Loading… Page 1. Pitt Campus Recreation Facility Hours Winter Break 2017.pdf. Pitt Campus Recreation Facility Hours Winter Break 2017.pdf. Open. Extract. Open with. Sign In. Main menu. Displaying Pitt Campus Recreation Facility Hours

Late Renewal Application.pdf
Home Phone Cell Phone. 3. Business Address. WYOMING Business Address City State Zip. Business Phone Business Fax. OTHER Business Address City ...

Checklist_FF (renewal).pdf
Page 1 of 1. CPG-FTEB-BLAD-Form No.18/rev00/10.06.16. FAIR TRADE ENFORCEMENT BUREAU. Business Licensing and Accreditation Division.

Member Application / Renewal
Individual Membership: $10. Student/Parent/Retiree: $10 (Full---time students, retired educators, non---educator parents). School Group Memberships: $150.

Renewal Checklist my19 -
Half-off Cardboard Boat Regatta Day or weekend pass (Girl and Adult) ... D. S. Other rocker patches may be earned at signature events throughout the year.

Facility Capacities.pdf
CHULA VISTA HIGH SCHOOL. Dance Room 86. Game/Meeting Room 86. Gymnasium 400. DISTRICT OFFICE. 1130 FIFTH AVE. Board Conference Room (by ...

Checklist_FF (renewal).pdf
Page 1 of 1. CPG-FTEB-BLAD-Form No.18/rev00/10.06.16. FAIR TRADE ENFORCEMENT BUREAU. Business Licensing and Accreditation Division.

License Renewal Guide.pdf
education highest degree, teaching license, select box for PDC options, selection box for return. notification, approve notification, daily digest. The PDP toolbox ...

Facility Location with Hierarchical Facility Costs∗ 1 ...
server locations, etc. ... We then focus on a subclass of submodular cost functions which we call .... Then facilities are the file servers, and clients are the users (or ...

facility construction
Cleveland County Board of Education (the “board”) and the facility design ... to be adapted to various purposes and to be adjusted to changes in technology or ...