Request for Change of Membership Category

PERSONAL DETAILS

Title *

First Name *

Last Name *

Mobile *

Email Address *

Postal Address *

Suburb *

State *

Postcode *

ADA SA Id

ADA Id (if known)

PI Insurer *

WORKING INFORMATION - PRINCIPAL WORKPLACE

Current average hours worked per week *

Practice Name

Practice Address

Practice Phone

Is this practice

Please select if you are

CATEGORY CHANGE

DECLARATION

I declare that the information I have provided is true and correct
I understand that I must notify the Australian Dental Association SA Branch Inc. in writing ofany changes to my status and/or contact details, or update my profile myself through theadasa.asn.au website.

*Signature of member *

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Date *

Category Descriptions

Click here for Subscription Rates for 2023/24

Dentist Full

A dentist who, being registered as a dentist in Australia, is admitted in accordance with theConstitution and By-Laws

Dentist 14.8 hours

A member who works less than 770 hours per subscription year (14.8 hours per week), wherethe reckoning of hours includes any and all paid duties undertaken by the member where being aregistered dentist is a requisite for those duties.

Dentist Postgraduate

A dentist who is a full-time graduate or undergraduate student proceeding to a formal degree orqualification related to dentistry and who is also engaged in paid dental employment exceeding385 hours per subscription year (7.4 hours per week). This form of concessional membership willbe limited to a period not exceeding 3 years.Dentist RetiredA dentist eligible for registration within Australia, who is a member of a State Branch and who hasbona fide retired from the active practice of dentistry.

Dentist over 70 + 30 years

A member who has attained the age of 70 years and has been an active member for not less than30 years.Dentist UnemployedA dentist who is currently unemployed as a dentist and is seeking employment as a dentist inAustralia.

Dentist Parental Leave

A dentist who is on unpaid parental leave for a period of no more than two years.