Regulation 18(3).
1. Full name.
2. Sex.
3. Date of Birth.
4. Private address.
5. Date of registration as a dental practitioner in the register kept under section 14 of the Dentists Act 1984 and registration number, dental qualifications registerable under that Act and when obtained.
6. Address of proposed Health Board or primary care NHS trust premises where emergency dental services will be undertaken.
7. Details of current and/or recent, within the last two years, clinical activities in dentistry.
8. Whether he has been suspended by the Tribunal.
9. Whether he is indemnified against claims relating to the practice of dentistry in relation to dentistry performed by himself and if he is indemnified, documentary evidence of that fact.
10. Details of any limitations imposed by the Secretary of State for the Home Department which restricts his ability to work in any specific capacity in Scotland.
11. A declaration as to whether–
(a)he has been convicted of a criminal offence bound over or cautioned in the United Kingdom or elsewhere, or is currently the subject of any proceedings which might lead to such a conviction, order to bind over or caution;
(b)he has been, or is currently subject to any action by his professional body or by any licensing or regulatory body in the United Kingdom or elsewhere,
and if so, details, including approximate dates, of where the action or proceedings were brought, the nature of that action or proceeding and any outcome.”