Do any of the following apply to you (now or in the past):
- Criminal convictions or police cautions
- Disciplinary or personal conduct issues
If the answer is Yes please provide dates as well as full details in the box below.
Have you ever had professional indemnity/insurance:
- Refused, cancelled (including a decline to renew) or made void
- Offered with non-standard terms or conditions imposed such as an increased subscription
If the answer is Yes please provide dates as well as full details in the box below.
IMPORTANT! – Your personal information and data
When interacting with MPS, you may choose to give MPS information about your criminal convictions and offences (including alleged offences), your health, race, ethic origin, sex life, sexual orientation and trade union membership (“Special Category Data”). This happens where that information is relevant to your membership or the actual or potential provision of advice, assistance or indemnity. We may also receive Special Category Data about you from others in connection with membership or advice, assistance or indemnity (e.g from a complainant, claimant, witness, expert, court or regulator).
To find out more about how we collect, use and handle your data including Special Category Data, please see the Privacy Statement on our website dentalprotection.org.
When you tick the box below, you expressly consent to MPS processing your Special Category Data for the purpose of providing you with membership and its benefits (including assistance and indemnity).
IMPORTANT! – Please read, sign and add the current date below.
By submitting this form, you agree and confirm that:
(i) You wish to apply for membership of MPS subject to the Memorandum and Articles of Association
(ii) You understand that any failure to disclose full and accurate details may delay your application and/or if you are accepted into membership could result in the suspension and/or withdrawal of membership benefits and/or the cancellation and/or termination of membership
(iii) You understand that membership is not conferred automatically and is subject to approval by MPS
(iv) You acknowledge that any subscription payments made are subject to verification and that acceptance of a payment by MPS does not of itself confirm membership and/or entitlement to request benefits
(v) You will inform us if your personal circumstances or scope of practice change
(vi) We may seek information from other professional defence organisations, insurance companies, employers, and/or other third parties in respect of membership and that they may release to us such information
(vi) For the purposes of the South African law and The Protection of Personal Information Act (4 of 2013), we may obtain, process, retain and transfer your personal data as set out in the Privacy Statement on our website dentalprotection.org/