ࡱ> 7<6y 'bjbj *,{{@@@@@TTTThT4uuu!######$G]@uuuuuG@@u @@!u!:,0o)%!" 0 ^L^^@$uuuuuuuGGuuuuuuu^uuuuuuuuu : MARYLAND STATE BOARD OF DENTAL EXAMINERS SPRING GROVE HOSPITAL CENTER % BENJAMIN RUSH BUILDING 55 WADE AVENUE/TULIP DRIVE % CATONSVILLE, MARYLAND 21228 Phone: (410) 402-8501 % Fax: (410) 402-8505 %  HYPERLINK "http://www.dhmh.maryland.gov/dental/SitePages/Home.aspx" www.dhmh.maryland.gov/dental/SitePages/Home.aspx CHANGE OF INFORMATION REQUEST The law requires that dentists, dental hygienists, and dental radiation technologists shall notify the Board in writing within 60 days of any change of home and/or office address. This is very important since the Board is required only to attempt to contact you at the address you have on file. The Board is authorized to proceed with its duties, including discipline, after it has attempted to contact you at the address on file, with or without your participation. Failure to notify the Board of an address change may result in your failure to receive a renewal application, which may in turn lead to disciplinary action for practicing on an expired license or certification. The Board must by law have a valid address for you. The address that you provide is the address of record that is available for public information requests. The Board does not send licenses, certifications, or registrations to post office boxes. Please provide a full mailing address and a phone number at which you can be reached during the day. Untimely notification to the Board of an address change will result in a late fee of $10. ______________________________________________________________________________________________________________________ Name of Record: License Number: ______________________________________________________________________________________________________________________ Notice for Mailing List The information collected is for the purposes of the Boards functions under the Md. Health Occ. Code Ann., Title 4. You have a right to inspect, amend, and correct this information. The Board may permit inspection of this information or make it available to others only as permitted by Federal and State law. The Board may sell or provide a list of licensees names and addresses to professional associations and other entities. Under the Maryland Public Information Act, Md. State Govt Code Ann. 10-617, you may request in writing that your name be omitted from such lists. ______________________________________________________________________________________________________________________ PLEASE DARKEN THE APPROPRIATE BOX __________________________________________________________________________________________________________ What information has changed? % Name % Home Address % Work Address % E-mail Address % Home Phone Number % Work Phone Number ______________________________________________________________________________________________________________________ NAME CHANGE ______________________________________________________________________________________________________________________ Previous Name: New Name: ______________________________________________________________________________________________________________________ If you are requesting a change of name, please submit a copy of a legal name change document, marriage certificate, or divorce decree. ______________________________________________________________________________________________________________________ ADDRESS CHANGE ______________________________________________________________________________________________________________________ Old Mailing Address New Mailing Address ______________________________________________________________________________________________________________________ Is this your % work or % home address? Is this your % work or % home address? Street: Street: ______________________________________________________________________________________________________________________ City: City: ______________________________________________________________________________________________________________________ State: Zip: State: Zip: ______________________________________________________________________________________________________________________ PHONE NUMBER CHANGE ______________________________________________________________________________________________________________________ Home Number Work Number Old: ( ) _____________________________________________ Old: ( ) _____\ f = > ^ _  g8FN\45v  $$$/%A%%%& &J&N&Q&&ܧʞ h9}5CJU h? 5>* h9}6 h9}56h9}5>*CJ h9}>*CJ h9}5 h9}5CJ h9}CJ h9}5>*hQh% 0Jh% jh% Uh? h9}>R0 ? @ ^ _   fg8^045T$a$$a$v   4j($)$$$$/%C%`$a$_______________________________________ New: ( ) _____________________________________________ New: ( ) ____________________________________________ E-MAIL ADDRESS CHANGE ______________________________________________________________________________________________________________________ New E-Mail Address: I affirm that the contents of this document are true and correct to the best of my knowledge and belief. Further, I authorize the Board to update their records to reflect this information. 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