EFTA00521430.pdf

EFTA00521430 Eta IMPARTMENT Or CONGIONIP UM*: August 7, 2017 Dental Board of California 2005 Evergreen Street, Suite 1550, Sacramento, California 95815 P (916) 263-23001 F (916) 263-2140 I www.breeze.ca.gov Karyna Shuliak 6100 Red Hook Quarter, Suite B-3 St Thomas, VI 00802 RETURN PAYMENT NOTICE RE: DDS 65268 The Dental Board of California is returning the following remittance because: The enclosed remittance is being returned because it was received incomplete. Please complete the required information on the remittance and return the remittance to the Board with the enclosed form(s) and a copy of this notice. Example of required information may be the following: Personal checks: Date of Check Pay to the Order of Signature Written dollar amount Numerical dollar amount REMITTANCE TYPE AMOUNT Personal Check. Money Order, Company Check, Cashiers check PERSONAL CHECK $687.00 Bank of America If ou need additional clarification, please contact Isis Stanley, the Cashier at: Money orders: Purchaser's signature Purchaser's address Pay to the order of Payee's address DATED REMITTANCE NUMBER Sincerely, The Dental Board of California 8/2/2017 176 EFTA00521431 Page 5 of 6; Dental License Renewal, 4408.RNWL03.032816 v. Renewal Application SHULIAK, KARY DDS65268 (Return entire page. Fold according to instructions on reverse side.) Question 1: Continuing Dental Education Read each statement carefully and mark the appropriate answer. A. Have you completed and can document 50 hours of approved continuing education in the last two years? B. Have you completed and can document completion of a course in Basic Life Support by the AHA or ARC, PACE or CERP? C. Have you completed the mandatory 2 hour course in Infection Control? D. Have you completed the mandatory 2 hour course in California Dental Practice Act? E. Is this your first renewal and you are not required to have CE units? Yes No Did you check Yes to statements "A," through "D," above, as required for active renewal? • If Yes, check box "A," and box "C," below. (No CE Units are required until license is reactivated.) • If you would like to renew Inactive, check box "B," below. • If this is your first renewal and you are not required to have CE units, answer yes to statement "E." above and check box "A," and "C," below. Question 2: Change of Address Has a change of address occured? • If Yes, check Box "E," below and complete the Change of Mailing Address on the reverse side. Question 3: Conviction Disclosure Since you last renewed your license, have you had any license disciplined by a government agency or other disciplinary body, or, have you been convicted of any crime in any state, the U.S.A. and its territories, military court or a foreign country? (Please read information on page 2 before answering.) • If Yes, check box "F," below. • If No, check box "G," below. Question 4: Fingerprints '- Have you furnished a full set of fingerprints to the Department of Justice as required by Title I 6, California Code of Regulations Section 1008? (Please read information on page 2 before answering) • If Yes, check box "H" below. • If No, check box "1" below. Dental Board of California — Dental License Delinquent Renewal LICENSEE NAME SHULIAK, KARYNA LICENSE NO. DDS65268 LICENSEE MUST CHECK CORRECT BOXES 'A' Renew Active 'Be O V 15? r 1f Renew Inactive CE Completed /CE Waiver Change of Address (fill in reverie aide) Conviction Disclosure - Yes Conviction Disclosure - No Fingerprint - Yes Fingetpnnt - No (DO NOT DETACH) EXPIRATION DATE 05/31/17 AUG 04 nil AMOUNT DUE NOW $687.00 -0- SIGNATURE REQUIRED I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signature Date 361004 01419014 0 I41910 0 06 52 68 5 010 S 3117 0 0 0 687 0 0 0 0 0 68 7 0 0 EFTA00521432 BUSINESS. CONSUMER SERVICES, AND HOUSING AGENCY- Department o/ Consumer Atreus GOVERNOR EDMUND G. BROWN. JR. e• e•••••••••• =ICS ..... MS •1 et Ce•SuMCO • 0.01. LICENSEE NAME SHULIAK, KARVNA DENTAL BOARD OF CALIFORNIA 2005 Evergreen Street Suite 1550 Sacramento, CA 95815 (916) 263-2300 www.dbc.ca.gov Dental License Delinquent Renewal Notice LICENSE NO. DD565268 EXPIRATION DATE 05/31/17 I. Renewal Instructions AMOUNT DUE NOW 5687.00 Attention: • To Renew Online, visit www.breeze.ca.gov. Online renewals are processed in 48-72 hours. If not renewing online, please read the renewal instructions below. Allow 6-10 weeks for processing your renewal when renewing by mail. • Do not send the delinquent fee amount unless your renewal will be postmarked 30 days after the expiration date of your license. • YOU MAY NOT ENGAGE IN THE PRACTICE OF DENTISTRY AFTER THE EXPIRATION DATE UNLESS THE LICENSE IS RENEWED. • Failure to complete the CE certification and sign at the bottom of page 5 will result in a delay of your renewal. Renewal Checklist: O IMPORTANT: Read all instructions. Answer the questions on the application by checking the appropriate boxes and sign and date the certification statement at the bottom of page 5. Failure to correctly complete the renewal application and documentation will result in processing delays. Applications received without a signature will not be processed. O Complete the required information on pages 3-6 in black or blue ink and make a copy for your records. O Sections 1 dun 5 of the Dental Healthcare Workforce Survey on page 3 must be completed. The information collected in this survey will be publicly available in accordance with state law. O Continuing Education (CE) information must be completed. Read the Continuing Education Requirements on page 2 then carefully mark the appropriate answers on page 5. O Return pages 3-6 in the enclosed envelope with a check or money order made payable to the Dental Board of California (DBC). Make sure the return address shows through the window of the envelope. Dental License Renewal Notice, 4408.RNWL03.032816; Page I of 6 EFTA00521433 Page 3 of 6; Dental License Renewal, 4408.RNWL03.032816 SHULIAK, KARY DDS65268 no. Dental Healthcare Workforce Survey Sections 1, 2, 3, 4, and 5 are required. Business and Professions Code section 1715.5 requires completion of this survey. The survey information collected will be publicly available in accordance with state law. I. LICENSE NUMBER: 2. LICENSE TYPE: 324 O O O O O DDS RDH RDFIEF RDHAP RDA RDAEF 6 6 3. EMPLOYMENT STATUS: O Full-time clinical practice in CA (32+ hours per week) $ Full-time clinical outside CA (32+ hours per week) Ci Pan-time clinical practice in CA (Less than 32 hours per week) O Administrative/Faculty Employment (No Direct Patient Care) O Retired O Other practice or employment status 4a. PRIMARY PRACTICE LOCATION: If you provide patient care, please indicate the zip code of your primary practice location (U.S. only) and the number of hours spent each week at this location. 4b. SECONDARY PRACTICE LOCATION: If you provide patient care in a second location, please indicate the zip code of that practice location (U.S. only) and the number of hours spent each week at this location. ZIP CODE 0 Vt ZIP CODE HOURS PER WEEK 1 HOURS PER WEEK 5. POSTGRADUATE TRAINING: Indicate the total years of training completed after dental school (accredited by the Committee on Dental AccreduatiOn in a dental specialty recognized by the American Dental Association). O 1 O 2 O 3 O 4 O 5+ is None 6. DENTAL PRACTICE/SPECIALTY and BOARD CERTIFICATIONS or PERMITS: (mark specialty classifications and Board Certifications) )8( General Practice O Prosthodontics O Max il lo facial O Oral Pathology O Endodontics O Public Health O Orthodontics O Facial Cosmetic Surgery O Oral Radiology O Pediatric Dentistry O Periodontics O General Anesthesia O Oral Conscious Sedation O Conscious Sedation 7. ETHNIC BACKGROUND (Optional): Mark all that apply O African American / Black r African O American Indian / Native American / Alaskan Native Asian O Cambodian O Korean O Chinese O Thai O Indian O Vietnamese O Indonesian O Other Asian O Japanese Latino I Hispanic O Central American O South American O Puerto Rican Caucasian / White / European / Middle Eastern O Other O O O Cuban Mexican Other Hispanic O Decline to State Native Hawaiian / Pacific Islander O Fijian O Filipino O Guamanian O Hawaiian O Samoan O Tongan O Other Pacific Islander 8. FOREIGN LANGUAGE (Optional) In addition to English, indicate additional languages in which you are fluent: O American Sign O Farsi O Hmong O Lao O Punjabi O Thai Language O French O Ilacano O Mandarin p< Russian O Turkish O Arabic O German O Italian O Mien O Samoan O Vietnamese O Armenian O Hebrew O Japanese O Polish O Spanish O Decline to State O Cambodian O Hindi O Korean O Portuguese O Tagalog O Other: O Cantonese EFTA00521434 ESTATE CI F CALIFORNIA. I ca ❑EPARTMENT OF CONSUMER AFFAIRS NM- Business and Profession Code Section 114.5 requires all boards, bureaus, committees and commissions within the Department of Consumer Affairs to ask whether an applicant or licensee is serving in. or has previously served in, the military. Answering this question is optional but if you have checked "YES' below, please complete and return this insert with your renewal coupon. Are you currently serving, or have you previously served, in the military? YES 0 If checked YES, please retum this form with your renewal, completing the information below. Name: License Type: License Number: INS-00IALL-01-20150922 EFTA00521435 aaionsawia 1 autnctai. CZINSLINTr I •II Mr CO ANA') • ( (03.NC Ace NCY • OtYVI I %WM, SD1/401T401: INIONKJ.P CS Ot PatIANT CONSUMCP•rIA*3 DENTAL BOARD OF CALIFORNIA 2005 Evergreen Street. Suite 1550, Sacramento, CA 95815 P (916) 263-2300 F (916) 263-2140 I www.dbc.ca.gov Electronic Mail (Email) Address Requirement Notice: All Dental Board applicants and licensees must report to the Board his or her electronic mail address no later than July 1, 2016. Business and Professions Code Section 1650.1 requires all applicants and licensees of the Dental Board of California to report to the board his or her electronic mail address, and will require the board to annually send an electronic notice to each applicant and licensee that requests confirmation of the applicant's or licensee's electronic mail address. If you have not yet submitted your electronic mail address to the board, please do so now. To submit by email send to Dentalboard@dca.ca.gov, or to submit by fax send to (916) 263-2140. Include your full name and license number, and license type. INS-440D BC-13-20160720 EFTA00521436