This form must be received by the NDEB office prior to the Application Deadline date of August 15, 2013

for participation in the 2013 Examination.

The National Dental Examining Board of Canada Le Bureau National dExamen Dentaire du Canada

CONFIRMATION OF DEGREE COMPLETION

Instructions
Section 1 - To be completed by Participants for the Dental Specialty Core Knowledge Examination Please complete Section 1 of the attached form and forward it to the Registrars Office or equivalent at the University from which you obtained your specialty degree. Forms completed by an affiliated college will not be accepted. This form must be completed by the University appearing on your dental degree. Section 2 - To be completed by University Registrar or Equivalent The individual named in Section 1 has made an application to participate in the National Dental Examining Board of Canadas (NDEB) Dental Specialty Core Knowledge Examination and requests that confirmation of their degree be forwarded to the NDEB. Please complete Section 2 of this form and return the original form in a sealed envelope directly to: NDEB, 80 Elgin Street, 2nd Floor, Ottawa, Ontario, Canada K1P 6R2. Please note that forms mailed by participants will not be accepted.

This form must be received by the NDEB office prior to the Application Deadline date of August 15, 2013 for participation in the 2013 Examination. Please refer to the Instructions on page 1 for detailed directions.
The National Dental Examining Board of Canada Le Bureau National dExamen Dentaire du Canada

CONFIRMATION OF DEGREE COMPLETION SECTION 1: To be completed by Participants for the Dental Specialty Core Knowledge Examination.
Family (Last) Name: Given (First) Name:

Previous Family Name:

Date of Birth (dd/mm/yy):

Post-Secondary Institution:

Dates Attended (dd/mm/yy):

Dental Degree Awarded:

Date Awarded:

Student ID at Institution:

I authorize the release of my academic information to the National Dental Examining Board of Canada for the purposes of participating in the NDEB Dental Specialty Core Knowledge Examination.

Participants signature

Date

SECTION 2: To be completed by University Registrar or equivalent. Please complete Section 2 of this form and return the original form in a sealed envelope directly to: NDEB, 80 Elgin Street, 2nd Floor, Ottawa, Ontario, Canada K1P 6R2.
I hereby confirm that the individual named above attended
(name of institution)

Date Started
(dd/mm/yy)

Date Completed
(dd/mm/yy)

Degree Awarded

on
(dd/mm/yy)

I have read and verified the information provided above,

Name of official completing this form: Title:

Address:

Telephone:

Fax:

Email:

Signature of Registrar/Dean

Date

Original Official Stamp/Seal of the University