6 Crescent Road, Toronto, ON Canada M4W 1T1

T: 416.961.6555 F: 416.961.5814 Toll-Free: 1.800.565.4591 www.rcdso.org

Jurisprudence andEthics Online CourseRegistration Form(For new applicants only)

Please complete the following form in full and submit via scanned email to cripley@rcdso.org or by fax to

416-922-1507. You will receive an email from the College within 3 business days with an unique PIN number and

instructions on how to access the online course.

Please note that this course is intended for dentists who are seeking registration in Ontario. In order to qualify for this

course, you must have already graduated or intend to graduate from dental school in less than 6 months.

The Jurisprudence and Ethics course is available in electronic format only and must be completed online. In

order to complete this licensure requirement, you will need a valid email account to gain access to the site.

In addition, the results of this course and examination will only be valid for registration purposes for a period of 3 years

from the date the exam was completed. Therefore, if it is not your intention to be registered to practise in Ontario for

more than 3 years, kindly register for the course at a date closer to when you intend to apply for a licence.

FIRST NAME SECOND NAME

LAST NAME GENDER: Male Female

ADDRESS 1

ADDRESS 2

CITY PROVINCE / STATE COUNTRY

POSTAL / ZIP CODE PHONE NUMBER

NAME OF DENTAL SCHOOL

MONTH & YEAR OF GRADUATION

EMAIL ADDRESS

04/ 13_3344