EFTA00524026.pdf

Application Summary 5/9/19 5:14 PM License Type: Dentist License Number: File Number: 51564 Application: DDS - Renewal Application Application Number: 6821663 Application Date: 05/09/2019 (mm/dd/yyyy) Page 1 of 3 Application Questions Have you served, or are you currently No serving, in the U.S. Armed Forces? Personal Detail First Name: KARYNA Last Name: SHULIAK Birthdate: *ri m. Addresses License Related Addresses Address of Record Warning: In order to protect your privacy and identity, address will not be displayed. Renewal Questions Do you certify that you have completed and No can provide proof, upon request by the Board, that you meet the continuing education requirements as define by Title 16, California Code of Regulations Section 1017? Select "First Renewal" if the following is true: I am exempt from continuing education because this is my first renewal. Do you certify that you have furnished a full Yes set of fingerprints to the Department of Justice as required by Title 16, California Code of Regulations Section 1008? Since you last renewed, have you had any No license disciplined by a government agency or other disciplinary body; or have you been convicted of any crime in any state in the USA and its territories, military court or a foreign country? Current Dental License Status: Inactive Workforce Survey II 1557447770457 EFTA00524026 5/9/19 5:14 PM Page 2 of 3 License Number: License Type: DDS Employment Status: Other practice or employment status Zip Code: 802 Hours Each Week: 0 Total Years: None Workforce Survey Practice & Certs General Practice Y Prosthodontics N Maxillofacial N Oral Pathology N Endodontics N Public Health N Orthodontics N Facial Cosmetic Surgery N Oral Radiology N Pediatric Dentistry N Periodontics N General Anesthesia N Oral Conscious Sedation N Conscious Sedation N Workforce Survey Ethnic Background Decline to State Y Workforce Survey Foreign Language Attachments Fees Biennial Renewal fee for Inactive DDS $650.00 Total Amount Due: $650.00 Applications are not considered submitted for processing until payment is received. Attestation II IIIIIIIIIIIIIIIIIIIIIIIIIIIMIIIIIIIIIIIIII Ill 1557447'70457 EFTA00524027 5/9/19 5:14 PM Page 3 of 3 I declare under penalty of perjury under the laws of the State of California that the forgoing is true and correct. Signature: Date: 1557447770457 EFTA00524028