1964_DENTISTS_(REGISTRATION_AND_DISCIPLINARY_PROCEDURE)_REGULATIONS — Page 17

1977 Ed.]

Dentists (Registration and Disciplinary Procedure) Regulations

[CAP. 156

A 17

[Subsidiary]

4. I hold the following qualifications--

Declared at

this

day of..

19.........

Before me,

Commissioner for Oaths

or

Notary Public

at

Photograph

FORM 3

DENTISTS REGISTRATION ORDINANCE

(Chapter 156)

CERTIFICATE OF REGISTRATION

No.

(s. 10 & reg. 7.] L.N. 177/77.

I hereby certify that the following is a true copy of particulars extracted from the entry in the Register-

Name

Address

Date of Registration

Fee paid: $450, or exempt under section 30 for the reason

stated below

FORM 4

[Deleted, L.N. 177/77}

Qualifications

Photograph

Registrar.

19......