/ American Board of Endodontics
PreliminaryApplicationforCertification

Ihereby make application to the American Board ofEndodontics,to be declared Board Eligible and to participate in the Certification

Processofthe American Board ofEndodontics.

EducationallyQualified
Endodontist / An endodontistwho has successfullycompleted and has been issueda certificate in endodontics from an advanced education program in endodontics accredited bytheCommission onDental Accreditation oftheADA.
Board EligibleEndodontist / AnEducationallyQualifiedEndodontistwhose application and credentials have the approval oftheBoard.

PersonalInformation

LastName (Family Name)FirstNameMiddle Initial

StreetAddressCityState/ProvinceZip/PostalCodeCountry

E-MailPhone (include area or country/city code)

It is theresponsibilityofthe applicantto keepa current address, email and telephone numberon file. Please notifythe AAE’sMembershipDepartmentwhen anyofyour contact information changes.TheABE is notresponsible for missed communicationswhen the applicant does not have current information on filewith theAAE.

Education

Advanced Specialty Education Programin EndodonticsDate and Year Certificate in EndodonticsAwarded

ApplicationProcessingInstructions

Pleasereturn this application,notarized copyof yourCertificate inEndodontics and TrackSelectionForm along

with a Cashier’s Check/Money Order/Personal or Business Check made payable to the ABE in the amount of $250 to:

AmericanBoardof Endodontics
750 W. Lake Cook Road Suite 137 / Phone:847/947-8619
Buffalo Grove, IL 60089 / E-Mail: /

over please

Pleasereadthefollowingstatementscarefullyandindicateyourunderstandingandagreementby signingbelow:

1.IherebyapplytotheAmericanBoardofEndodontics(ABE)forexaminationbytheABEandissuancetomeofa certificate,inaccordancewithandsubjecttotheproceduresandregulationsoftheABE. Underpenaltyofperjury,I declarethattheinformationthatIhaveprovidedistrue. Ihavereadandagreetotherequirements and conditions set forthinthePolicyandProceduresManualoftheAmericanBoardof Endodonticscovering the certification process, theadministrationofcertificationexaminations, exam and yearly fees, and the ABE’s policies. Iagreetodisqualificationfromexaminations,to denialofcertification,andtoforfeitureandredeliveryofanycertificategrantedmebytheABEintheeventthatany of theanswersorstatementsmadebymeinthisapplicationarefalseorintheeventthatIviolateanyoftheABE’srules orregulations. I authorizetheABE tomakewhatever inquiriesand investigationsit deemsnecessary toverify my credentials and professional standing.

2.IherebyreleasetheABE,itsmembers,directors,officers,examiners,andagentsfromany andall liabilityarising out of orinconnectionwithany actionoromissionby any oftheminconnection with this application, the certification process, anyexaminationorreviewgivenbytheABE,anyscorerelatingthereto,thefailuretoissuemeacertificate,orany demandforforfeitureorredeliveryofsuchcertificate,andIagreetoindemnifytheABEandsaidpersonsandhold themharmlessfromanylawsuit,complaint,claim,loss,damage,costorexpense,includingattorneys’fees,arisingout oforinconnectionwithsaidcertificationactivities. IUNDERSTANDTHAT THEDECISIONASTOWHETHERI QUALIFYFORACERTIFICATERESTSSOLELYANDEXCLUSIVELYWITHTHEABEANDTHATTHEDECISION OFTHE ABE ISFINAL.

3.IunderstandthatthisapplicationandanyinformationormaterialreceivedorgeneratedbytheABEinconnectionwith thisapplicationorwiththecertificationprocesswillbekeptconfidentialandwillnotbereleasedunlessIhave authorizedsuchreleaseorsuchreleaseisrequiredby law. However,Iunderstandthat the fact that I have or have not beencertifiedandtheeffectivedateofmycertificationaremattersofpublicrecordandmaybedisclosed. Finally,I allowtheABEtouseinformationfrommyapplicationandsubsequentexaminationforthepurposeofstatistical analysis, provided that mypersonal identificationwith that information has been deleted.

4.IunderstandthatIcanbedisqualifiedfromtakingorcontinuingtositforanexamination,or fromreceivingexamination scores,and that I may be required to retake an examination if, at its sole discretion, the ABE determines through proctor observation, statistical analysis, or any other means available to it, that I was engaged in collaborative, disruptive, or other irregular behavior before, during the administration of, or following, the examination, or if the ABE determines that the integrity or validity of the examination, otherwise, is in question. I further understand that, in some instances, while the evidence of irregularity is sufficiently strong to cast doubt upon the validity of scores, such evidence may not enable the ABE to identify the particular individuals involved. In any such circumstances, I understand the ABE reserves the right to withhold the scores of all Candidates, including Candidates not directly implicated in the irregularity and, if necessary, to require all Candidates to take an additional examination at a later date under conditions which will ensure the validity of all scores.

5.Iunderstandthatthecontentofthecertificationexaminationisproprietary andstrictly confidentialinformation. I hereby agreethatIwillnotdisclose,eitherdirectlyorindirectly,anyquestionoranypartofanyquestionfromtheexamination toany personorentity. Iunderstandthattheunauthorizedreceipt,retention, possession, copying or disclosure of any examinationmaterials,includingbutnotlimitedtothecontentofanyexaminationquestion,before,during,orafterthe examination,maysubjectmetolegalaction. Suchlegalactionmayresultinmonetarydamagesand/ordisciplinary action including denial or revocation of certification.

6.Iunderstandthatthisapplication,andallactionsoftheABEormeinconnectionwiththeapplication,examination, certificationprocess,shallbegovernedbythelawoftheStateofIllinoisandthatanylegalactionarisingthere

from shall be brought and tried onlyin theCircuitCourt ofCookCounty,Illinois.

7.I haveread and agree to abide bytheABE SpecialAccommodationsPolicy.

8.IHAVEREAD AND UNDERSTANDTHE ABOVE STATEMENTS AND I INTENDTOBE LEGALLYBOUND BYTHEM.

Applicant’sSignature–Your signature must be notarized.

Name ofApplicant

Signature ofApplicant

Subscribed and sworn to before me this dayof , 20.

My CommissionExpires: NotaryPublic(SEAL)

TheAmerican Board of Endodontics

Certification bythe American Board ofEndodontics (ABE)helps to assure the publicand health professionals thattheyarebeingserved byan endodontistwho hassuccessfullycompleteda

rigorousexamination processand remains in good standingin theircommunityon an on-goingbasis.

Forthisreason,theABE requires thatyou answereach ofthe followingquestions. Ifyou answerYes toanyofthesequestions,pleaseprovidea fullexplanationoftheanswerandreturnthe explanation with thisform.

1. Haveanydisciplinaryactions been initiatedorareany pendingagainstyou bya statelicensingboardormilitary tribunal? / Yes / No
2. Has yourlicense to practice in anystateorjurisdiction been denied,relinquished,limited,suspended,reprimanded, censured,orrevoked? / Yes / No
3. Have you been suspended,sanctioned,orotherwise restricted fromparticipatingin anyprivate,federal,orstate health insurance programforreasons relatingto the practice ofdentistry? / Yes / No
4. Has yourDEA (narcotics)registration certificatebeen relinquished,limited,suspended,revoked orchallenged? / Yes / No
5. Have you been sanctioned,suspended,censured,or expelled froma professional dental ormedical organization forreasonsotherthan non-paymentofdues? / Yes / No
6. Have you been convicted of,been named as adefendantin anycriminal proceedings,orpleaded nolo contendere to,any criminal conductormisdemeanorsotherthan minortraffic violations? / Yes / No
7. Haveyou hadhospital orinstitutional appointmentsor privilegesdenied,reduced,limited,notrenewed,suspended, diminished,revoked,orrelinquished forreasons relatingto the practice ofdentistry? / Yes / No

BYSIGNINGBELOW,YOUAGREETOSUPPLEMENTYOURRESPONSEIFANYANSWERTO THE ABOVE QUESTIONS CHANGES IN THEFUTURE.

Date

Signed_