The Royal College of Dentists of Canada

Section A: Personal Information

Name

Specialty

Address

City/Town

Province/State

Postal Code/Zip Code

Country

Phone

Cell Phone

Email Address

Year of Specialty Training

Year Fellowship Conferred

English Language Skills (please select all that apply)SpeaksUnderstandsAble to Examine

French Language Skills (please select all that apply)SpeaksUnderstandsAble to Examine

Please list your experience in developing, grading, or administering examinations:

Teaching Commitments:

University Appointments:

Section B: References

Reference Name

Relationship

Phone Number and/or

Reference Name

Relationship

Phone Number and/or

Section C: CV

Please upload a current CV below. Please note that the file size limit is 16MB.

BROWSE YOUR COMPUTER

Section D: Special Accomendations

Do you have any special considerations or limitations that the College would need to
accommodate?

Section E: Agreement

By clicking yes below, you agree to the following: The Royal College of Dentists of Canada
is committed to receiving and treating personal information in confidence. The information in this
application is collected and used by and on behalf of the College for the purpose of evaluating
the applicant’s eligibility and for any correspondence or recordkeeping necessary to manage the
volunteer’s relationship with the College. I hereby declare that all information provided in this
application is true and accurate, I authorize and consent to the College making inquiries of third
parties as are necessary to evaluate my eligibility and I acknowledge and understand that any
inaccuracy or misrepresentation will be grounds for immediate dismissal.
Yes

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Fellowship Examiner Application Form

Section A: Personal Information

Section B: References

Section C: CV

Section D: Special Accomendations

Section E: Agreement