New Membership Application Form

Click here for Subscription Rates for 2023/24

PERSONAL DETAILS

Title *

First Name *

Middle Name

Last Name *

Preferred Name

Gender *

Mobile *

Date of Birth *

Email Address *

Australian Resident *

YesNo

Home Address

Street address *

Suburb *

State *

Postcode *

Postal Address (must be in South Australia)

Please tick if same as above

Address

Suburb

State

Postcode

REGISTRATION

(AHPRA) Registration No. *

Federal ID no. (if known)

Professional Indemnity Insurance Provider *

PI Policy No. *

If you wish to apply for Guild Insurance at a discounted member rate please call Guild Insurance on 1800 810 213 or visit guildinsurance.com.au

DENTAL QUALIFICATION

Initial Dental Qualification (ie BDS) *

Year of graduation *

Graduating University *

Town & Country where qualification obtained *

Additional Qualifications

Dental Qualification

Graduating University (City & Country)

Year of Graduation

Dental Qualification

Graduating University (City & Country)

Year of Graduation

Dental Qualification

Graduating University (City & Country)

Year of Graduation

WORKING INFORMATION - Principal Workplace

Please select if you are:

Not Working

Employed

Contracted

Associate

Partner

Sole Owner

Current average hours worked per week *

Practice Name

Practice Address

Suburb

State

Postcode

Country

Practice Phone Number

Employment Area:

Government

Private

University

Are you a tutor with TAFE SA? *

Are you a tutor with The University of Adelaide, School of Dentistry? *

Are you an examiner with Australian Dental Council? *

REFEREE DETAILS

To apply for membership you are required to provide the names of two professional referees, both must be financial dentist members of the Australian Dental Association and unrelated to you. Nominated referees will be contacted to provide written references to support your application.

ADC students and Branch Transfers are not required to complete this section.

Referee 1

Full Name

ADA Member of which State

Federal ID

Email Address

Referee 2

Full Name

ADA Member of which State

Federal ID

Email Address

DECLARATION

I hereby apply for membership of the Australian Dental Association SA Branch Incorporated.I agree to be bound by the Constitution and Code of Ethics. These documents are available on the ADA SA website or will be provided to you on request.

I undertake at all times to uphold the professional and ethical obligations of membership.

I understand that application of membership also includes mandatory membership to the Australian Dental Association Incorporated (Federal) by virtue of requirements under the Constitution of the Australian Dental Association on SA Branch Incorporated.

I further understand that I must notify the Australian Dental Association SA Branch Incorporated in writing or update my profile myself via the website, of any change of status (e.g. changing number of declared hours).

Have you currently or in the past had a statutory complaint upheld against you? *

Has your registration to practice in any jurisdiction on ever been suspended, revoked or had any restriction or condition imposed? *

Have you ever had membership of this Association, or a similar organisation, refused or terminated? *

If you have answered “yes” to any of these three questions please provide details on a separate sheet.

By signing this form I declare that the information I have provided is true and correct.

Signature of applicant *

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Date *

PAYMENT

Subscription Rates and Category Descriptions for 2023/24 - click here

Category applying for

Total cost for ADA SA & ADA Inc. Membership (refer to subscription rates for costs)

I wish to pay my subscription monthly

Please complete the Monthly Autopay Collection Agreement Form click here

I wish to pay the total amount due by credit card

Card Type

VisaMastercard

Cardholder Name

Card Number

Card Expiry

CVV

Cardholder Signature

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Please click ‘NEXT’ to move forward to the ‘SUBMIT’ button, ensuring your application is lodged.

Please refer to the Important Notices Document for informationon your Duty of Disclosure obligations and how Guild Insurancemanages your privacy.

(ADC Students only to complete) - INSURANCE INFORMATION

HISTORY

Have you undertaken the Australian Dental Council (ADC) examination procedure?

What date did you graduate?

Have you practiced outside of Australia?

If you answer “yes” to any of the above questions, Your application will be referred to Guild InsuranceLimited for review.

In the last 5 years have you:

Had an insurance application rejected or policy cancelled by an insurer?

Had a renewal refused or a compulsory excess or special condition imposed?

Been subject to a claim of the type covered by the proposed insurance (professional indemnity, public and products liability)?

Become aware of any facts or circumstances which may give rise to a claim of the type covered by this proposed insurance?

Been subject to any investigation, examination, or inquiry for professional misconduct? (This includes conditions, undertakings or reprimands attaching to your professional registration)?

If you answer “yes” to any of the above questions, please attach details with your application.Your application will then be referred to Guild Insurance Limited for review and You may be contacted foradditional information.

INSURANCE DECLARATION

I acknowledge that I have read and understood the Privacy Policy and Duty of Disclosure from GuildInsurance Limited that were provided to me with this application form.

Yes

I declare that the information I have provided is true and correct

Full Name

Signature

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Date

Insurance issued by Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233791 and subject to terms, conditions, and exclusions. Guild Insurance supports ADA SA through the payment of referral fees. ADA SA is an authorised representative of Guild Insurance. Please refer to the policy wording and policy schedule for details. For more information call 1800 810 213.

(ADC Students only to complete) COMPULSARY TO COMPLETE

Date you enrolled to ADC

Year you expect to graduate

Confirmation enrolled in ADC Program

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Please provide proof that you are a candidate actively participating in the Australian Dental Council (ADC) examination - (www.adc.org.au/assessments/dentists/)

*ADC students - please complete Guild Insurance information on last page.

(Post Graduates to complete ONLY) - STUDY INFORMATION

Enrolment Date

Institution of Study

Expected Graduation Date

Course Name

Confirmation enrolled in Post Graduate Course

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Please provide proof that you are currently enrolled in a dental post graduate course in any University in Australia.