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SCHEDULE 2

PART IIINFORMATION, DECLARATIONS CERTIFICATE, UNDERTAKINGS AND CONSENTS, TO BE INCLUDED IN AN APPLICATION FOR INCLUSION IN THE SECOND PART OF THE DENTAL LIST

1.  An application shall contain the following information:—

(a)the applicant’s full name, sex, date of birth, private address, telephone number and e-mail address and National Insurance number, if the applicant has one;

(b)date of first registration and any subsequent registration as a dental practitioner in the register of dentists and registration number, dental qualifications registerable under the Dentists Act 1984(1) and when obtained;

(c)where applicable, the address of the proposed premises and, in the case of a mobile surgery, the address to which correspondence may be sent;

(d)chronological details of the applicant’s professional experience (including the starting and finishing dates of each appointment together with explanation of any gaps between appointments) with any additional supporting particulars, and an explanation of why the applicant was dismissed from any post;

(e)whether the applicant will assist with the provision of general dental services which are restricted to orthodontic treatment;

(f)details of any list or equivalent list from which the applicant has ever been disqualified, conditionally disqualified, removed, suspended, contingently removed or suspended or to which admission was refused or conditionally granted together with reasons for such disqualification, conditional disqualification, removal, suspension, refusal or conditional admission;

(g)name and addresses of two referees who are willing to provide clinical references relating to two recent posts as a dentist each of which lasted at least 3 months without a significant break and which may include a current post, or, where this is not possible a full explanation and name and address of an alternative referee or referees;

(h)if the applicant is a national of an EEA state, evidence that the applicant has a knowledge of English which, in the interests of the applicant and of patients who may receive general dental services from the applicant, is necessary for assisting with the provision of general dental services;

(i)whether any limitations have been imposed by any government organisation which restrict the applicant’s ability to work in any specified capacity in Scotland and, if so, the details of these;

(j)if the applicant is, or has been where the outcome was adverse, the subject of any investigation by the Agency or any other body in relation to fraud; and

(k)the name and address, telephone number and e-mail address of the dentist, and the name, registered number, registered office, telephone number, e-mail address and the names of all the directors of any body corporate, whom the applicant will assist in the provision of general dental services.