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DocuSign Envelope ID: DAAE2CBD-CD76-4858-84F5-E9B3F7DOOBBC <br /> Page 1 of 1 <br /> Raiim to main menu page. <br /> "* PRThT THIS RECEIPT FOR YOUR RECORDS,*** <br /> If you hold an Anesthesia/Sedation Peimit, you need to renew it now as well since it is a separate <br /> process. <br /> To do so, please return to the License Renewal section of the Board's main website, select the permit <br /> type and renew. <br /> 0.! oft <br /> Z7-3 <br /> ,- <br /> North Carolina State Board of Dental Examiners <br /> Receipt for Annual Renewal <br /> Date: 11/9/2015 8:05:25 AM <br /> Order ID: AU1FDBDBOESF <br /> Fee: $329.00 <br /> Registrant: Diane C. Shugars, License: 5138 <br /> Address Payment information <br /> Card: <br /> 2; <br /> (2,rd <br /> 2: : ; -a: Expiration: 11/19 <br /> CHAPEL HILL,NC 27516 19 Diane C. Shugars <br /> Apt N, 201 Barksdale Drive <br /> CHAPEL HILL,NC 27516 <br /> Email: DIANE SHUGARS@DENTISTRY.UNC.EDU Your license Expires: 3/31/2017 <br /> https://www.rnembershase.net/ncbde/dopaymentvs.asp 11/9/2015 <br />