Student BDS New Membership Application

Declaration

1. I hereby apply for membership of the Australian Dental Association SA Branch Incorporated.

2. I agree to be bound by the Constitution and Code of Ethics.

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

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

5. I further understand that I must notify the Australian Dental Association SA Branch Inc. in writing of any change of status or details.

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

Signature *

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Date *

PERSONAL DETAILS

Title *

First Name *

Middle Name

Last Name *

Preferred Name

Gender *

Mobile *

Date of Birth *

Email Address (Please use professional email, not University one) *

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

STUDY INFORMATION - Bachelor of Dental Surgery (BDS)

Graduating University *

Year of Graduation *

INSURANCE INFORMATION

By ticking this box I acknowledge that I am aware of the terms, conditions and exclusions that appear in the Important Notice and Policy. I understand that although the policy is issued on a ‘claims made’ basis, I can make a claim under the policy after it expires, provided I have advised the ADA of facts that might give rise to a claim against me as soon as was reasonably practicable after I became aware of those facts, but before the expiry of the Period of Cover. *

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.

DECLARATION

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