1. Full name.
2. Sex.
3. Date of birth.
4. Private address.
5. Date of registration as a dental practitioner in the register kept under section 14 of the Dentists Act and registration number, dental qualifications registrable under that Act and when obtained.
6. Address of proposed practice premises and in the case of any mobile surgery, the address to which correspondence may be sent.
7. Proposed days and hours of attendance and whether patients will be seen by appointment only and in the case of any mobile surgery, particulars of places to be visited regularly by the dentist and the times of those visits.
8. Undertaking to provide general dental services in the area of the Board.
9. Whether intending to practise—
(a)as a single-handed practitioner; or
(b)as a partner and if so the name and address of each intended partner and whether or not his name is included in the dental list; or
(c)as an associate and if so the name and address of each intended associate and whether or not his name is included in the dental list.
10. The names of any assistants he or any person referred to in paragraph 9(b) or (c) intends to employ or already employs at the proposed practice premises.
11. Present or most recent appointment and whether any previous experience in the provision of general dental services.
12. Whether the general dental services to be provided are restricted to orthodontic treatment.
13. Whether there is access to the proposed dental surgery without the use of stairs.