DPL 1 Form (o.

Date $ssued

Application for inclusion in the General Dental Performers List

1. Personal Details
Dr/Mr/Mrs/Ms/Miss: Surname: .. Forenames: .. Maiden/previous name: Date of Birth: D D M M

Se!:

Please tick relevant box

Male

Female

"ountr# of Birth: $ a%ree to the pu&lication of m# date of &irth in the Performers List Yes Private Address: No

..

.. .. 'emem&er to advise the ()SSP of an# chan%e of address Private *elephone: Mo&ile *elephone:.. Private +mail: ..

Are #ou appl#in% to ,oin the Dental Performers List as:

*ic- as appropriate

A provider only A provider/performer (contractor A performer

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DPL 1
A performer !ocational "ental Practitioner

)hich of the follo.in% appl# to #our inclusion/ P"# a$reement 'oc(m services %"# contract &"# services

"irectly provided ')* services

+. )ost N,##P/')* Please indicate to .hich Local 0ealth Board List #ou .ish to &e included: 1Please indicate 2(+ onl#3 ()SSP 1South +ast )ales3
"ardiff and 4ale 5niversit# Local 0ealth Board ".m *af Local 0ealth Board (-.ondda /ynon 0af and Mert.yr areas Aneurin Bevan Local 0ealth Board (*laena( %1ent2 /aerp.illy2 Ne1port2 Monmo(t.s.ire and 0orfaen areas

()SSP 1Mid and )est )ales3

A&erta.e Bro Mor%ann.% 5niversit# Local 0ealth Board (Neat.2 *rid$end2 Port 0albot and #1ansea areas 0#.el Dda Local 0ealth Board (/armart.ens.ire2 Pembrokes.ire and /eredi$ion areas Po.#s *eachin% Local 0ealth Board

()SSP 1(orth )ales3

Betsi "ad.aladr Local 0ealth Board (Flints.ire2 "enbi$.s.ire2 %1ynedd2 ,rex.am2 /on1y and An$lesey areas

Please indicate yo(r preferred incl(sion date on t.e "ental Performers 'ist: D D M M

Please note t.at incl(sion on t.e Performers 'ist 1ill be s(b3ect to receipt of a satisfactory /-* certificate2 and overseas Police -eport/4t.er #(itable *ody -eport (1.ere appropriate .
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DPL 1

For Dentists 5nderta-in% Locum )or1to &e completed &# dentists .ishin% to have their names included and pu&lished in the locum list6 please indicate .hich areas #ou are prepared to .or- in 3

/ardiff Mert.yr 0ydfil -.ondda2 /ynon 0aff !ale of %lamor$an

*laena( %1ent /aerp.illy Ne1port Monmo(t.s.ire 0orfaen

/armart.ens.ire /eredi$ion Pembrokes.ire Po1ys /on1y "enbi$.s.ire Flints.ire %1ynedd 5sle of An$lesey ,rex.am

*rid$end Neat./Port 0albot #1ansea

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DPL 1 7. Practice Details

D+*A$LS 2F *0+ P'A"*$"+ *2 )0$"0 25 A'+ 82$($(G 2' A**A"0+D 1$F APPL$"ABL+3 PL+AS+ $("L5D+ D+*A$LS 2F ALL P'A"*$"+S (ame of "ontractor: . Main Practice Address: . .. *elephone (um&er of Practice: . Additional Practice Addresses . .

MA$( P'A"*$"+ P'+M$S+S A'+:9

Ne1ly converted or ref(rbis.ed facility &xistin$ facility Mobile

(ame of GDP *rainer 14DPs onl#3: ... GD" (um&er of *rainer 14DPs onl#3:

Start and +nd Date of *rainin% in this Practice: Start: D D M M +nd: D D M M

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DPL 1

:. Dental ;ualifications
GD" 'e%istration (um&er:

Date of 5< 'e%istration as a Dentist: D D M M

Dental 4ocational *rainin% (um&er 1if appropriate3

"ate of iss(e .. D+*A$LS 2F ;5AL$F$"A*$2(S ;ualification (ame of $nstitution and countr# %ained Date of %ainin% ;ualification

P'&A#& P-4!5"& &!5"&N/& 4F A'' 67A'5F5/A054N#

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DPL 1

=. Dental Performers List Details

Part A > 1All practitioners3 8. Are yo( c(rrently incl(ded in any 'ocal )ealt. *oard/P/0 "ental Performers 'ist9 Yes No a 5f yes2 please $ive details and contact name/telep.one n(mber of t.e 'ocal )ealt. *oard/P/0: and b 5f yes2 please $ive details of all sc.emes for 1.ic. yo( are a contractor incl(din$ sc.eme contact n(mbers. Please also indicate 1.ic. of t.ose sc.emes is relevant to yo(r incl(sion. +. "o yo( .ave an o(tstandin$/deferred application for incl(sion in any 'ocal )ealt. *oard/P/0 "ental Performers 'ist9 Yes a No

5f yes2 please $ive details and contact name/telep.one n(mber of t.e 'ocal )ealt. *oard/P/0

3.

)ave yo( ever been removed2 contin$ently removed2 conditionally incl(ded2 s(spended or ref(sed entry from any 'ocal )ealt. *oard/P/0 or e;(ivalent list9 Yes No a 5f yes2 please $ive details and contact name/telep.one n(mber of t.e 'ocal )ealt. *oard/P/0 or e;(ivalent body and an explanation 1.y

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DPL 1
PA'* B /4-P4-A0& "&N05#0# (*ody /orporate 4nly to be completed by contractors 1.o are re$istered as a "ental *ody /orporate 1it. t.e %eneral "ental /o(ncil. Note : "irectors of a "ental *ody /orporate 1.o are dentists2 1ill be incl(ded on t.e list as a performer2 it is t.e corporate body itself 1.ic. is re$istered as a contractor. Name of /ompany: .. -e$istered No 1it. %"/:.. "ate -e$istered:.... -e$istered Address of /ompany .. .. Post /ode: ..

0el: Fax: . &mail: . Please provide details and contact name/telep.one n(mber of t.e ')*/P/0 1it. 1.om yo(r .ead office is re$istered. .. .. .. Name2 address2 dates of birt. and %4//%M//%"/ or -P#%* re$istration (1.ere applicable of persons 1.o are "irectors of t.e "ental *ody and ot.ers 1.o yo( intend to employ in t.e area. (/ontin(e on a separate s.eet if necessary .. .. .. .. .. ..
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DPL 1
.. .. PA'* " 9 1*o &e completed onl# &# those practitioners .ho are6 or have &een in the last ? months6 a Director of a Bod# "orporate3

Are yo( c(rrently a "irector of a body corporate incl(ded in t.is ')*s professional list9 Yes q No q 5f no2 are yo( c(rrently a "irector of a body corporate incl(ded in any ot.er ')*s professional lists9 Yes q No q 2' .ave an o(tstandin$/deferred application for incl(sion in a professional list9 Yes q No q 5f yes2 please $ive details of t.e ')* and t.e name and re$istered office of t.e body corporate <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< )as t.e body corporate ever been removed2 contin$ently removed or s(spended from any ')*/P/0 list or e;(ivalent list2 or .ad an application for incl(sion eit.er ref(sed or conditionally incl(ded in a ')*/P/0 list or e;(ivalent list9 Yes q No q

5f yes2 please provide details of t.e ')*/P/0 or e;(ivalent body to$et.er 1it. an explanation 1.y. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< 1(ote: Bod# "orporate means an# compan#/&usiness re%istered such .ith the General 2ptical "ouncil6 General Dental "ouncil6 General Medical "ouncil or the 'o#al Pharmaceutical Societ# of Great Britain3

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DPL 1

PA'* D > 1*2 B+ "2MPL+*+D B ALL P+'F2'M+'S A**A"0+D *2 A P'A"*$"+3 5 am indemnified a$ainst claims relatin$ to t.e %"#/P"# practice of myself or t.at performed by a dep(ty 1.ose 1ork is (nder my direction. Yes q No q 1Please suppl# documentar# evidence of indemnit#3

A**+(DA("+ Please $ive details of proposed days and .o(rs of attendance. <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

Patients 1ill be seen by appointment only Yes q No q "o yo( provide ort.odontic treatment only Yes q No q

D+*A$LS 2F P+'F2'M+'S Please list t.e names of all ot.er dentists 1.o 1ill be party to t.e same contract <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<

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DPL 1

?. Statement of Professional +!perience

Please list in t.e follo1in$ order 1it. t.e most recent appointment listed first on eac. occasion: 8. %eneral "ental Practice &xperience (incl(din$ vocational trainin$ experience +. )ospital Appointments =. 4t.er &xperience (incl(din$ overseas experience Please provide f(ll s(pportin$ partic(lars of yo(r experience. Any $aps in service m(st be mentioned2 $ivin$ explanations. +!perience/Appointment9 (please incl(de contact name and address information of most recent post Date From Date *o 'eason for Leavin%

"ontinue on a separate sheet if necessar#

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DPL 1 @. 'eferees
Please provide names and addresses of t1o referees 1.o are 1illin$ to provide clinical references relatin$ to t1o recent posts (1.ic. may incl(de any c(rrent post as a performer 1.ic. lasted at least t.ree mont.s 1it.o(t a si$nificant break. (ame *itle Position Address (ame *itle Position Address

*elephone Fa! +9mail 0o. lon% have #ou -no. this person and in .hat capacit#

*elephone Fa! +9mail 0o. lon% have #ou -no. this person and in .hat capacit#

0.e referees s.o(ld normally be representatives (%"P or /ons(ltants of yo(r last t1o clinical posts2 1.ere t.at employment lasted for a contin(o(s period of at least t.ree mont.s. 5f t.is is not possible a f(ll explanation m(st be $iven belo1. -eferees must not be related to yo(. $t is #our responsi&ilit# to ma-e sure that #our referees are e!pectin% to &e contacted and are in a position to provide #ou .ith a reference.

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DPL 1 A. +ntitlement to .or- in the 5<

8. +. Are yo( a *ritis. /iti>en or &&A National9 ,ere yo(r dental ;(alification examinations taken in t.e &n$lis. lan$(a$e9 Yes Yes No No

5f t.e ans1er to ;(estion + is No2 please provide evidence of proficiency in t.e &n$lis. lan$(a$e (e.$. 5nternational &n$lis. 'an$(a$e 0estin$ #ystem2 5&'0# test2 report 1it. a score of at least ?.@ in eac. of t.e sections incl(din$ academic readin$ and 1ritin$ mod(les and an overall score of at least A . 5f yes2 please provide a certificate of $rad(ation from a 7B "ental #c.ool (trained in &n$lis. . Please s(pply ori$inal doc(ments. *ritis. /iti>ens and &&A Nationals s.o(ld proceed to t.e next section of t.is form. 4t.er applicants s.o(ld complete ;(estions =C@. =. "o yo( .ave evidence of entitlement to enter Yes and 1ork in t.e 7B (e.$. settled stat(s2 spo(se of *ritis. /iti>en etc or are yo( in t.e 7B (nder t.e /ommon1ealt. ,orkin$ )olidaymakerDs #c.eme9 "id yo( enter t.e 7B as a doctor2 or obtain a c(rrent entry clearance to do so2 before 8 April 8EF@ ,.at is yo(r immi$ration stat(s9 'imited leave to remain (ntil .. ("ate 5ndefinite leave to remain #(b3ect to 1ork provisions #elf &mployed 4t.er2 please specify ... Yes No

4. @. a. b. c. d. e.

No

Please s(pply ori$inal evidence of yo(r immi$ration stat(s2 i.e. !5#A. 5f s(b3ect to 1ork permit provisions please provide details of t.e applicationDs pro$ress. 5f selfC employed please enclose doc(ments confirmin$ selfCemployed stat(s.

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DPL 1

B. Additional $nformation
/linical 5nterests: . . . 'an$(a$es #poken: .....
(ot.er t.an &n$lis.

.. /an yo( cons(lt in t.ese lan$(a$es: Yes No

1C. "onsent to Sharin% $nformation

*o &e completed &# all applicants: 5 consent to t.e N)# ,ales #.ared #ervices Partners.ip s.arin$ my contact details 1it. t.e 'ocal "ental /ommittees in its area and t.e "ean of Post$rad(ate &d(cation Yes No

*o &e completed &# all applicants e!cludin% 4ocational Dental Practitioners: 5 a$ree to my name and contact details bein$ incl(ded on t.e N)# ,ales #.ared #ervices Partners.ip loc(m list Yes No

Si%ned: ... Full (ame: . Date: ..

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DPL 1

11. Declarations and 5nderta-in%s

5 declare t.at 5 am a re$istered dental practitioner incl(ded in t.e dental re$ister of t.e %"/ in t.e name s.o1n on pa$e one of t.is application. 5 a$ree (ntil and after my application is finally determined to notify t.e ')* of any material c.an$es to my application2 1it.in A days of t.em .appenin$. 5 a$ree to inform t.e ')* 1it. t.e details of any c.an$e in my private address 1it.in +F days of its occ(rrence. 5 a$ree to $ive t.e ')* t.ree mont.s notice of my intention to 1it.dra1 from t.e primary dental performers list (nless it is impracticable to do so. 5 a$ree to notify t.e N,##P if 5 intend to 1it.dra1 from t.e ')*Ds %eneral "ental Performers 'ist (0.e 'ist if 5 apply to be accepted or am accepted on to t.e list of anot.er ')* or e;(ivalent body. 5 a$ree to coCoperate 1it. an assessment by t.e N/AA2 1.en re;(ested to do so by t.e ')*. 5 a$ree to participate in t.e appraisal system provided on be.alf of t.e ')*. (Not applicable to armed forces %"Ps and a$ree to send t.e ')* a copy of t.e statement s(mmarisin$ t.at appraisal. 5 a$ree to provide a /-* &n.anced /ertificate in relation to myself to t.e ')* or if t.e ')* considers t.at t.e c.eck is s(fficiently o(t of date to (nder$o a f(rt.er s(c. c.eck in accordance 1it. #ection 88@ of t.e Police Act 8EEA.5f 5 .ave been resident in t.e 7B for less t.an six mont.s at t.e time t.e &n.anced /ertificate is prod(ced2 5 a$ree to provide a f(rt.er /-* &n.anced /ertificate six mont.s from t.e date of my incl(sion in t.e "ental Performers 'ist. 5 a$ree to a re;(est bein$ made by t.e ')* to any employer or former employer2 licensin$2 re$(latory or ot.er body in t.e 7nited Bin$dom or else1.ere2 for information relatin$ to a c(rrent investi$ation2 or an investi$ation 1.ere t.e o(tcome 1as adverse re$ardin$ myself or t.e body corporate referred to in ;(estions =2 G and 8F follo1in$. 0.e term HemployerI to incl(de for t.e p(rposes of t.is para$rap. any partners.ip of 1.ic. t.e performer is or 1as a member.

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DPL 1

5 a$ree t.at s.o(ld t.e ')*2 1.en considerin$ my application2 consider it necessary to re;(est from me f(rt.er information2 references or doc(mentation in order to decide t.e applications o(tcome 5 1ill comply 1it. any s(c. reasonable re;(ests. 5 a$ree not to perform any primary dental services in t.e area of anot.er ')* or e;(ivalent body from 1.ose "ental Performers 'ist2 "ental 'ist2 #ervices 'ist2 #(pplementary 'ist or e;(ivalent list 5 .ave been removed2 except 1.ere t.at removal 1as at my re;(est or in accordance 1it. -e$(lation 8J(? of t.e N)# (Performers 'ists (,ales -e$(lations +JJG2 or -e$(lation F(= of t.e "ental -e$(lations or any e;(ivalent provision in #cotland or &n$land2 1it.o(t t.e consent in 1ritin$2 of t.at ')* or e;(ivalent body 5 a$ree to comply 1it. t.e re;(irements of -e$(lation F= of t.e N)# (%eneral "ental #ervices /ontracts (,ales -e$(lations +JJ? ($ifts 2 or -e$(lation F8 of t.e N)# (Personal "ental #ervices A$reements (,ales -e$(lations +JJ? ($ifts 5 a$ree if 5 am not a /ontractor2 to comply 1it. t.e re;(irements of t.e above para$rap. as t.o($. 5 am a /ontractor. *he follo.in% items i to iii appl# to 4ocational Dental Practitioners *rainees onl#: (i (ii (iii 5 a$ree not to perform any primary dental service except 1.en actin$ for and (nder t.e s(pervision of2 my trainer: 5 a$ree to 1it.dra1 from t.e dental performers list if 5 fail to complete my vocational trainin$: 5 a$ree to provide (pon completion of trainin$ satisfactory evidence t.at 5 .ave completed trainin$.

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DPL 1

Declarations and 5nderta-in%s "ontinued

$f #ou ans.er #es to an# of the follo.in% Duestions 1191B3 please %ive full e!planations 1includin% the names of relevant L0BEs/P"*Es6 appro!imate dates of .here an# investi%ation or proceedin%s .ere or are to &e &rou%ht6 the nature of those investi%ations or proceedin%s6 and an# outcome3 on pa%e FC follo.in% #our declarations. Please tic- &o!es as appropriate. 1. )ave yo( any o(tstandin$ applications2 incl(din$ a deferred application2 to be incl(ded in any list of anot.er ')*/P/09 Yes No

+. )ave yo( ever been removed2 contin$ently removed2 ref(sed admission or conditionally incl(ded in any ')* list or e;(ivalent list or are yo( c(rrently s(spended from s(c. a list9 Yes No

3. Are yo( a director of any body corporate t.at is incl(ded in any list of a ')*/P/0 or its e;(ivalent or .as an o(tstandin$ application (incl(din$ a deferred application for incl(sion in any list or e;(ivalent list9 Please Note: Body
Corporate means any company/business registered as such with the General Optical Council, the General Dental Council or the General Pharmaceutical Council.

Yes

No

! you ha"e answered yes to #uestion $ you must pro"ide the name and registered address o! that Body Corporate and details o! the %&B/PC' or e#ui"alent body concerned on page (.

G. ,ere yo( 1it.in t.e last six mont.s or at a time of t.e ori$inatin$ events2 a director of a body corporate2 1.ic. .as been ref(sed admission2 conditionally incl(ded2 removed2 contin$ently removed or is at present s(spended from a ')*/P/0 or e;(ivalent bodyDs list9 Yes No

@. "o yo( .ave any criminal convictions in t.e 7nited Bin$dom9 Yes No

?. )ave yo( ever been bo(nd over follo1in$ a criminal conviction in t.e 7nited Bin$dom9 Yes
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No

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DPL 1

Declarations and 5nderta-in%s "ontinued

A. )ave yo( ever accepted a police ca(tion in t.e 7nited Bin$dom9 Yes No

F. )ave yo( ever accepted a Fixed Penalty9 Yes No

E. )ave yo( ever accepted a conditional offer (nder section =J+ of t.e /riminal Proced(re (#cotland Act 8EE@(8 (fixed penalty: conditional offer by proc(rator fiscal or a$reed to pay a penalty (nder section 88@A or t.e #ocial #ec(rity Administration Act 8EE+(+ (penalty as alternative to prosec(tion : Yes No

8J. )ave yo( in proceedin$s in #cotland for an offence2 been t.e s(b3ect of an order (nder section +G?(+ or (= of t.e /riminal Proced(re (#cotland Act disc.ar$in$ yo( absol(tely: Yes No

88. )ave yo( been convicted else1.ere of an offence2 or 1.at 1o(ld constit(te a criminal offence if committed in t.e 7nited Bin$dom or are yo( s(b3ect to a penalty2 1.ic. 1o(ld be t.e e;(ivalent to bein$ bo(nd over or ca(tioned9 Yes No

8+. Are yo( c(rrently t.e s(b3ect of any proceedin$s 1.ic. mi$.t lead to s(c. a conviction2 1.ic. .ave not been notified to t.e ')*9 Yes No

8=. )ave yo( been s(b3ect to any investi$ation into yo(r professional cond(ct by any licensin$2 re$(latory or ot.er body2 1.ere t.e o(tcome 1as adverse9 Yes No

8G. Are yo( c(rrently s(b3ect to an investi$ation into yo(r professional cond(ct by any licensin$2 re$(latory or ot.er body9 Yes No

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DPL 1
8@. Are yo(2 to yo(r kno1led$e2 or .ave yo( ever been2 1.ere t.e o(tcome 1as adverse t.e s(b3ect of any investi$ation by t.e N)# /o(nter Fra(d and #ec(rity Mana$ement #ervice in relation to fra(d9 Yes No

Declarations and 5nderta-in%s "ontinued

8?. Are yo( s(b3ect to any investi$ation by anot.er ')* or e;(ivalent body2 1.ic. mi$.t lead to yo(r removal from any of t.at ')*Ds or e;(ivalent list9 Yes No

8A. Are yo( at present2 or .ave yo( ever2 1.ere t.e o(tcome 1as adverse2 been t.e s(b3ect of any investi$ation into yo(r professional cond(ct in respect of any c(rrent or previo(s employment9 Yes No

8F. )ave yo( been removed2 contin$ently removed2 ref(sed admission to or conditionally incl(ded in any list or e;(ivalent list kept by a 'ocal )ealt. *oard or e;(ivalent body2 or are yo( c(rrently s(spended from s(c. a list2 and if so 1.y and t.e name of t.at e;(ivalent body. Yes No

8E. Are yo( or .ave yo( ever been s(b3ect to a national dis;(alification9 Yes No

$f #ou ans.ered GnoH to &oth Duestions 7 and : a&ove #ou do not need to ans.er Duestion FC6 02)+4+' $F 25 A(S)+'+D +S *2 2(+ 2' B2*0 2F *0+S+ ;5+S*$2(S 25 M5S* A(S)+' ;5+S*$2( FC

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DPL 1 Declarations and 5nderta-in%s "ontinued

+J. 5f yo( are or .ave been in t.e precedin$ six mont.s or 1ere at t.e time of t.e ori$inatin$ events a director of a body corporate2 yo( m(st ans1er t.e follo1in$ ;(estions: C )as t.e body corporate any criminal convictions in t.e 7nited Bin$dom.9 Yes No )as t.e body corporate been convicted else1.ere of an offence2 or 1.at 1o(ld constit(te a criminal offence if committed in t.e 7nited Bin$dom2 or is s(b3ect to a penalty2 1.ic. is e;(ivalent to bein$ bo(nd over or ca(tioned9 Yes c No

5s t.e body corporate c(rrently s(b3ect to any proceedin$s 1.ic. mi$.t lead to s(c. a conviction2 1.ic. .ave not yet been notified to t.e ')*9 Yes No

)as t.e body corporate ever been s(b3ect to any investi$ation into its provision of professional services by any licensin$2 re$(latory or ot.er body2 1.ere t.e o(tcome 1as adverse9 Yes No

5s t.e body corporate c(rrently s(b3ect to an investi$ation into its provision of professional services by any licensin$2 re$(latory or ot.er body9 Yes No

5s t.e body corporate to yo(r kno1led$e at present2 or .as it ever been 1.ere t.e o(tcome is adverse2 t.e s(b3ect of an investi$ation by t.e N)# /o(nter Fra(d and #ec(rity Mana$ement #ervice in relation to fra(d9 Yes No

5s t.e body corporate c(rrently s(b3ect to an investi$ation by anot.er ')* or e;(ivalent body 1.ic. mi$.t lead to its removal from any performers list or e;(ivalent list9 Yes No )as t.e body corporate been removed from2 contin$ently removed from2 ref(sed admission to or conditionally incl(ded in any Performers 'ist or e;(ivalent performers list or is c(rrently s(spended from s(c. a performers list9 Yes No

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DPL 1

(ote: Please note that the 'eha&ilitation 2ffenders Act 1B@: does not appl# to %eneral dental practitioners for the purpose of this declaration. 2ffences considered GspentH under the Act must &e declared *he 'eha&ilitation 2ffenders Act 1+!ceptions 2rder3 allo.s emplo#ers of some occupational %roups and professionals6 includin% health care .or-ers6 to asapplicants for details of criminal convictions .hich .ould other.ise &e GspentH in terms of the Act. Such emplo#ers ma# as- Ge!empted DuestionsH .hen recruitin% to posts covered &# the +!ceptions 2rder. Posts covered &# the +!ceptions 2rder include: An# emplo#ment or other .or- .hich is concerned .ith the provision of health services and .hich is of such a -ind as to ena&le the holder of the emplo#ment as the person en%a%ed in that .or- to have access to persons in receipt of such services in the course of his normal duties. $f #ou have ans.ered #es to an# of the proceedin% Duestions please %ive details &elo.6 includin% appro!imate dates6 of .here the investi%ation of proceedin%s .ere or are to &e &rou%ht6 the nature of that investi%ation or proceedin%s6 and an# outcome. 1Please use a separate sheet of paper if reDuired3 <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<< <<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<<
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DPL 1 Declarations and 5nderta-in%s "ontinued

5 declare t.at 5 1ill inform t.e 'ocal )ealt. *oard in 1ritin$ 1it.in A days if: a 5 am convicted of any criminal offence in t.e 7nited Bin$dom: b 5 am bo(nd over to keep t.e peace in t.e 7nited Bin$dom: c 5 accept a police ca(tion in t.e 7nited Bin$dom:

d 5 accept a conditional offer (nder section =J+ of t.e /riminal Proced(re (#cotland Act 8EE@(8 (fixed penalty: conditional offer by proc(rator fiscal or a$ree to pay a penalty (nder section 88@A or t.e #ocial #ec(rity Administration Act 8EE+(+ (penalty as alternative to prosec(tion e 5 become2 in proceedin$s in #cotland for an offence2 t.e s(b3ect of an order (nder section +G?(+ or (= of t.e /riminal Proced(re (#cotland Act disc.ar$in$ me absol(tely: f 5 am convicted else1.ere of an offence2 or 1.at 1o(ld constit(te a criminal offence if committed in t.e 7nited Bin$dom2 or 5 am s(b3ect to a penalty 1.ic. 1o(ld be t.e e;(ivalent of bein$ bo(nd over or ca(tioned:

$ 5 am c.ar$ed in t.e 7nited Bin$dom 1it. a criminal offence2 or 5 am c.ar$ed else1.ere 1it. an offence 1.ic.2 if committed in t.e 7nited Bin$dom2 1o(ld constit(te a criminal offence: . 5 am notified by any licensin$2 re$(latory or ot.er body of t.e o(tcome of any investi$ation into my professional cond(ct2 and t.ere is a findin$ a$ainst me: i 3 5 become t.e s(b3ect of any investi$ation into my professional cond(ct by any licensin$2 re$(latory or ot.er body: 5 become s(b3ect to an investi$ation into my professional cond(ct in respect of any c(rrent or previo(s employment2 or if 5 am notified of t.e o(tcome of any s(c. investi$ation if adverse: 5 become to my kno1led$e t.e s(b3ect of any investi$ation by t.e National )ealt. #ervice /o(nter Fra(d and #ec(rity Mana$ement #ervice in relation to fra(d: or informed of t.e o(tcome of s(c. an investi$ation2 1.ere it is adverse: 5 become t.e s(b3ect of any investi$ation by anot.er 'ocal )ealt. *oard/P/0 or e;(ivalent body2 1.ic. mi$.t lead to my removal from any of t.at 'ocal )ealt. *oard/P/0Ds lists or e;(ivalent lists:

m 5 am removed2 contin$ently removed2 s(spended2 ref(sed admission to2 or conditionally incl(ded in any list or e;(ivalent list kept by anot.er 'ocal )ealt. *oard/P/0 or e;(ivalent body.

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DPL 1 Declarations and 5nderta-in%s "ontinued

5f so2 5 1ill $ive details of any investi$ation or proceedin$s 1.ic. 1ere or are to be bro($.t2 incl(din$ t.e nat(re of t.e investi$ation or proceedin$s2 1.ere and approximately 1.en t.at investi$ation or t.ose proceedin$s took place or are to take place and any o(tcome. 5 s.all also provide t.e same information concernin$ any *ody /orporate of 1.ic. 5 am2 .ave been d(rin$ t.e precedin$ six mont.s2 or 1as at t.e time of t.e ori$inatin$ events2 a "irector.

(.B. 2nl# information .hich .ill &e pu&lished in the pu&lic domain .ill &e that reDuired under 'e%ulation FF1:3 of the (0S 1Performers Lists3 1)ales3 'e%ulations FCC: as amended. All other information supplied .ill remain confidential unless disclosure is authorised &# 'e%ulation FC of the (0S 1Performers Lists3 1)ales3 'e%ulations FCC: as amended.

$ declare t.at 5 am a f(lly re$istered dental practitioner and 5 am incl(ded in t.e dental re$ister in t.e name s.o1n at t.e be$innin$ of t.is form. 5 $ive t.e above (ndertakin$s2 declarations and consent and $ 0+'+B D+"LA'+ t.at t.e information $iven .ere2 and on any contin(ation s.eet2 is tr(e and complete. $ consent to the Local 0ealth Board ma-in% contact .ith an# or%anisation it deems necessar# to verif# or validate an# of the information $ have provided in this application Si%ned: ... Full (ame: . Date: ..

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DPL 1
5n order to proceed 1it. yo(r application yo( m(st enclose t.e follo1in$ ori%inal items: /(rrent Ann(al re$istration certificate 1it. t.e %eneral "ental /o(ncil Post$rad(ate /ertificate of satisfactory completion of vocational trainin$ (or e;(ivalent "ental vocational trainin$ n(mber certification /(rrent "ental 5ndemnity 5ns(rance All ot.er certificates relatin$ to yo(r ;(alifications For 5< citiIens &orn in the 5<6 yo(r birt. certificate or passport For 5< citiIens &orn outside the 5< and for non 5< citiIens6 yo(r passport (yo(r birt. certificate is not acceptable &n$lis. 'an$(a$e /ertificate (only applicable to citi>ens of &&A co(ntries 1.ose first lan$(a$e is not &n$lis. and 1ere trained in co(ntries ot.er t.an t.e 7B or -ep(blic of 5reland /ompleted /-* application form and s(pportin$ doc(ments (if yo( .ave ever received an en.anced /-* disclos(re certificate please provide t.is also For ne1 7B residents a translated Police -eport/4t.er #(itable *ody -eport from yo(r previo(s overseas place of residence. (0.is report s.o(ld be less t.an six mont.s old.

$n all cases a&ove ori%inal certificates must &e provided to the ()SSP on &ehalf of the L0B.

PL+AS+ +(S5'+ *0$S F2'M $S F5LL "2MPL+*+D

Please ens(re t.e completed form is sent to t.e N)# ,ales #.ared #ervices Partners.ip2 #1ansea. All forms s.o(ld be sent to t.e follo1in$ address in t.e envelope provided. 5t is s($$ested t.at applications are sent by -ecorded "elivery: C "ental Performers 'ist /ontracts Mana$ement N)# ,ales #.ared #ervices Partners.ip 0.e 4ld1ay /entre =? 4rc.ard #treet #1ansea ,est %lamor$an #A8 @A6

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DPL 1

Data Protection (otice 0.e "ata Protection Act covers t.e personal information provided by yo( on t.is Application Form. A /onfidentiality A$reement $overns all o(r staff t.at may process yo(r information. ,e 1ill not kno1in$ly release yo(r personal details to any commercial or$anisation for marketin$ p(rposes 1it.o(t obtainin$ yo(r consent. $f #ou .ould li-e an# further information or if #ou do not .ish us to share #our personal information .ith an# particular or%anisation .ithout #our e!plicit consent6 please contact Darren Llo#d6 $nformation Governance Mana%er6 on CFBFC =CF@FB or e mail: Darren.Llo#dJ.ales.nhs.u-

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