SCHEDULE 2 APPLICATION FOR INCLUSION IN THE DENTAL LIST
Regulation 5

PART I information and undertaking to be included in an application for inclusion in the dental list
1 Full name.
2 Sex.
3 Date of birth.
4 Private address.
5 Date of registration as a dental practitioner in the register kept under section 14 of the Dentists Act 1984 and registration number and dental qualifications registerable under that Act and when obtained.
6 His vocational training number, if he has one.
7 Address of proposed practice premises and, in the case of any mobile surgery, the address to which correspondence may be sent.
8 Proposed days and hours of attendance and whether patients will be seen by appointment only and, in the case of any mobile surgery, particulars of places to be regularly visited by the dentist and the times of those visits.
9 Undertaking to provide general dental services in the area of the Health Board.
10 Whether intending to practise—
(a) as a single-handed practitioner; or
(b) as a partner and if so the name and address of each intended partner and whether or not his name is included in the Health Board’s dental list; or
(c) as an associate and if so the name and address of each intended associate and whether or not his name is included in the Health Board’s dental list.
11 The names of any assistants he or any person referred to in paragraph 10(b) or (c) above intends to employ or already employs at the proposed practice premises.
12 Present or most recent appointment and whether any previous experience in the provision of general dental services.
13 Whether the general dental services to be provided are restricted to orthodontic treatment.
14 Whether there is access to the proposed dental surgery without the use of stairs.
15 Whether he has been suspended by the Tribunal.

PART II information which may be included in an application for inclusion in the dental list
Details of any languages, other than English, spoken by the dentist.