Student application

Title:

Surname:

Forename:

Date of birth (dd/mm/yyyy):

Gender:

Dental school:

Other:

Expected date of graduation:

Course year:

Course:

Email address:

Confirm Email address:

Home address:

Term-time address
(if different to home address):

Preferred mailing address:

Telephone number:

Mobile number:

As a professional organisation protecting you in your career, we expect you to tell us about any current or previous criminal convictions, police cautions, disciplinary or similar issues you are or may have been involved with in the past. If any of these apply to you, please provide dates and details.

If you require any advice or assistance completing this form, please contact the Student Helpline on Freephone 1800 444 542

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DPL Australia Pty Ltd (DPLA) is a member of the Medical Protection Society Limited (registered in England No.36142) group of companies providing discretionary benefits, subject to Australian law, for dentists and other dental care professionals. These benefits are set out in the Memorandum and Articles of Association published on our website. Neither DPLA nor MPS are insurance companies.

DPL Australia Pty Ltd ABN 24 092 695 933, CAR No. 326134 is a Corporate Authorised Representative of MDA National Insurance Pty Ltd ABN 56 058 271 417, AFS Licence No. 238073. DPLA Members have access to the Dental Indemnity Policy underwritten by MDA National Insurance Pty Ltd.