Authority for Branch Transfer

PERSONAL DETAILS

DENTAL QUALIFICATIONS

INSURANCE DETAILS

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.

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DR00033