An applicant for a dental laboratory registration shall submit to the department the following:

(1) An application on forms provided by the department;

(2) A verification that the dental laboratory meets the requirements listed in RCW 70.352.050;

(3) An acknowledgment by the responsible person or supervising dentist who is licensed in this state attesting that the dental laboratory will provide written material disclosure to the prescribing dentist that contains the information required in RCW 70.352.030 (1)(e);

(4) An acknowledgment by the responsible person or supervising dentist who is licensed in this state attesting that the dental laboratory will disclose in writing to the prescribing dentist the point of origin of the manufacture of each prescribed restoration as required in RCW 70.352.030 (1)(f); and

(5) The fee required under WAC 246-315-990.