5/9/19 5:14 PM Page 1 of 3 License Type: Dentist License Number: || File Number: 51564 Application: DDS - Renewal Application Application Number: 6821663 Application Date: 05/09/2019 (mm/dd/yyyy) Have you served, or are you currently No serving, in the U.S. Armed Forces? First Name: KARYNA Last Name: SHULIAK Birthdate: laa! lala! ineiaiel License Related Addresses Address of Record Warning: In order to protect your privacy and identity, address will not be displayed. Do you certify that you have completed and No can provide proof, upon request by the Board, that you meet the continuing education requirements as define by Title 16, California Code of Regulations Section 1017? Select "First Renewal" if the following is true: | am exempt from continuing education because this is my first renewal. Do you certify that you have furnished a full Yes set of fingerprints to the Department of Justice as required by Title 16, California Code of Regulations Section 1008? Since you last renewed, have you had any No license disciplined by a government agency or other disciplinary body; or have you been convicted of any crime in any state in the USA and its territories, military court or a foreign country? Current Dental License Status: Inactive W(LQONT 000000 A pe 10021 EFTA00524026

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5/9/19 5:14 PM License Number: License Type: Employment Status: Zip Code: Hours Each Week: Total Years: DDS Page 2 of 3 Other practice or employment status 802 zo ° Ss @ General Practice Prosthodontics Maxillofacial Oral Pathology Endodontics Public Health Orthodontics Facial Cosmetic Surgery Oral Radiology Pediatric Dentistry Periodontics General Anesthesia Oral Conscious Sedation Conscious Sedation Z2e2e2e2e22222222 4 Decline to State < Biennial Renewal fee for Inactive DDS Total Amount Due: Applications are not considered submitted for processing until payment is received. W(IQONT 000000 A a 0221+ EFTA00524027

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5/9/19 5:14 PM Page 3 of 3 | declare under penalty of perjury under the laws of the State of California that the forgoing is true and correct. Signature: Date: W(1UONT 000000 WA AA a F021 + EFTA00524028