Authority for Branch Transfer

I request my ADA Membership to be transferred from (State) *

To (State) *

Effective Date *

Federal No (if known)

PERSONAL DETAILS

First Name *

Last Name *

Mobile *

Date of Birth *

Email Address *

Postal Address *

Suburb *

State *

Postcode *

DENTAL QUALIFICATIONS

Initial Dental Qualification *

Year of Graduation *

Graduating University *

AHPRA Registration Number

Registration Type (e.g. General, Endodontist)

INSURANCE DETAILS

Do you have dentist liability insurance with Guild *

If yes, what is your Policy Number?

Do you wish to continue insurance with Guild? *

If no, date you wish to cancel your policy

DECLARATION

I understand that in considering my application, the Australian Dental Association SA Branch Inc. mayneed to review my personal information relating to my current and previous dental registration, Associationmembership and professional indemnity insurance/claims history.

I consent to the Australian Dental Association SA Branch Inc. seeking access to such information and usingthat information for the purposes of considering my application and consent to the relevant organisationdisclosing such information.

*Signature of member *

Draw signature|Type signatureClear

Date *

DR00033