SCHEDULE “D”

to By-law #40-99 of the

MANITOBA DENTAL ASSOCIATION

STATEMENT OF PARTICULARS TO UPDATE OR RENEW PERMIT TO PRACTICE DENTISTRY AS A PROFESSIONAL CORPORATION

  1. NAME OF DENTAL CORPORATION:______

ADDRESS OF REGISTERED OFFICE:______

ADDRESS OF PRACTICE:______

2. / a)□ The Articles of Incorporation have not been amended since the last Statement of Particulars was filed with the Registrar;
OR
b)□ Attached to this Statement of Particulars are those amendments to the Articles of Incorporation which have been made since the last Statement of Particulars was filed with the Registrar. / c)
3. / The corporation is in good standing with the Director as defined in The Corporations Act of Manitoba. / d)

4.All of the persons or dental corporations who own voting shares in the corporation, each of whom is a licensed member of the Manitoba Dental Association or a dental corporation are:

Name / Address / Number and Class of Shares

SCHEDULE “D” to By-law #40-99 Page 2

5. / All of the persons or corporations who own non-voting shares and who are either licensed members of the Manitoba Dental Association, the spouse, common law partner or child of a licensed member, within the meaning of the Income Tax Act (Canada) or a corporation, each share of which is owned by a person hereinbefore referred to, are:
Name and relationship to licensed member / Address / Number and Class of Shares
6. / All of the persons who are directors of the corporation, each of whom is a licensed member of the Manitoba Dental Association are:
Name / Address / Number and Class of Shares
7. / The President of the corporation, who is a licensed member of the Manitoba Dental Association, is:
Name / Address / Number and Class of Shares
8. / Each person who will carry on the practice of dentistry for or on behalf of the corporation is:
a)a licensed member of the Manitoba Dental Association; or
b)an employee or dental auxiliary acting under the effective supervision and control of a licensed member through whom the corporation will be practicing dentistry.
9. / The corporation undertakes that it will at all times, while it is the holder of a permit from the Manitoba Dental Association, keep, perform and abide by all of its obligations in the practice of dentistry and all requirements of the Manitoba Dental Association.

SCHEDULE “D” to By-law #40-99 Page 3

MEMBER’S CERTIFICATE

I,______,

A currently licensed member(s) of the Manitoba Dental Association and a voting shareholder(s) and a director(s) of the corporation, hereby certify to the Manitoba Dental Association that:

  1. the information and particulars contained in the Statement of Particulars are true and complete;
  1. I have read the sections in The Dental Association Act pertaining to professional corporations and the Corporation By-law #40-99 of the Manitoba Dental Association, and am familiar with all of the rules pertaining to the practice of dentistry by a corporation; and
  1. that my relationship to the corporation, whether as a shareholder, director, officer or employee, does not affect, modify or diminish the application to me personally of the provisions of The Dental Association Act and by-laws of the Manitoba Dental Association.

______

SIGNATURE OF MEMBER(S) SIGNATURE OF MEMBER(S)

______

SIGNATURE OF MEMBER(S) SIGNATURE OF MEMBER(S)

______

DATE

Revised 7/15/2010