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AADB Self-Query Form
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American Association of Dental Boards 211 East Chicago Avenue, Suite 760 Chicago, IL 60611 Telephone (312) 440-7464 Clearinghouse for Board Actions Self-Query Form INSTRUCTIONS: Please type or legibly print in ink the information requested below. A notarized copy of this form along with $8.00 check, money order or credit card payment should be mailed to the American Association of Dental Boards at the address shown above. A copy of the results will be mailed to you within 10 business days from the date of receipt. Payment: Check/Money Order _____ Credit Card (Visa, MC & Amex) _________________________ Credit Card #______________________________ Expiration Date ________________ *Name: _________________________________________________________________ (Last) (First) (Middle) (Suffix) Alternative Name(s): ______________________________________________________ Mailing Address: _________________________________________________________ _________________________________________________________ Telephone #: ____________________________________________________________ *Date of Birth: ______/____/_______ Social Security #.: _______________________ Month Day Year *Professional School Attended: ______________________________________________ *Year of Graduation: _____________________ Degree _________________________ License No.:_____________________________________ State: __________________ Other State License(s) Held (License No. and State): ______________________________ _______________________________________________________________________ DEA #.: ______________________________ * Information requested must be completed in order to process the self-query. The reliability of reports produced by the Clearinghouse is dependent upon the accuracy and timeliness of the information provided by the reporting entities. The AADB will make no representations or warranties, either expressed of implied, as to the accuracy of the information and will assume no responsibility for errors or omissions that may be contained therein Your Signature Notarized Signature: __________________________________ Date: ____________________ Notary Public Signature: ______________________________ Signed Before me this Date: ___________________________ My Commission Expires: _______________________ (seal) |
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