NATIONAL DENTAL ASSISTING EXAMINING BOARD BUREAU NATIONAL D’EXAMEN D’ASSISTANCE DENTAIRE 204 - 2283 St. Laurent Blvd, Ottawa, Ontario K1G 5A2 Tel/Tél.: (613) 526-3424 • Fax/Téléc.: (613) 526-5560 • [email protected] Certificate Reprint Request Name appearing on original NDAEB Certificate. Please print clearly. Last Name: _______________First Name: _______________Middle Name: ________________ Street name/number_____________________________________________________________ Apt #: _____________________P.O. Box: ________________ City: _______________________ Province: ______________ Postal Code: _________________ Tel: ________________________ Country: _________________________ □ NDAEB Certificate number: __________________or □ NDAEB Registration Number_________________ Date of Birth (YY/MM/DD): ________________ Email: __________________________________ Which Dental Assisting program did you graduate from? ________________________________ Year of graduation: _____________ Persons requesting a new NDAEB Certificate because of a name change are requested to provide supporting documents. Change Name of Official Record to: Last Name: ______________ First Name: _______________Middle Name: __________________ Name to appear on certificate reprint: ______________________________________________ Current Address if different from above: Street name/number: _____________________________________________________________ Apt #: _____________________P.O. Box: ________________ City: _______________________ Province: ______________ Postal Code: _________________ Tel: ________________________ Country: _________________________
NATIONAL DENTAL ASSISTING EXAMINING BOARD BUREAU NATIONAL D’EXAMEN D’ASSISTANCE DENTAIRE 204 - 2283 St. Laurent Blvd, Ottawa, Ontario K1G 5A2 Tel/Tél.: (613) 526-3424 • Fax/Téléc.: (613) 526-5560 • [email protected] Reason for change: □ Marriage □ Divorce □ Other Documents to support request: □ Copy of marriage license □ Copy of Divorce Documents □ Copy of court order □ Other Signature: _________________________________ Date: ____________________ Please Note: If your supporting documents have not been issued in Canada you must then provide a certified true copy, notarized in Canada by a Lawyer, Notary Public or Commissioner of Oaths, translated to English. Fee and Payment: $50.00 CAD *The fee includes a reissuance of a paper copy certificate and a digital certificate. This is subject to change, in the future, at the discretion of the NDAEB. Payment notes: The NDAEB accepts bank drafts, or money orders. The NDAEB does not accept personal cheques or credit card payment. DO NOT SEND CASH
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