3/26/19 11:30 AM Page 1 of 1 License Type: Dentist License Number: || File Number: 51564 Application: Change of Address Application Number: 6822987 Application Date: 03/26/2019 (mm/dd/yyyy) PersonalDetail First Name: KARYNA Last Name: SHULIAK License Related Addresses Address of Record Warning: In order to protect your privacy and identity, address will not be displayed. Confidential Address Warning: In order to protect your privacy and identity, address will not be displayed. Effective Date: 03/26/2019 (mm/dd/yyyy) | certify under the penalty of perjury, under the law of the State of California that the information in this application and any attachments are true and correct. Signature: Date: SO UT UT a EFTA00524025