Australian Dental Prosthetists Association (Victoria)
ABN 67 005 999 806 / ACN 005 999 806
Promoting Excellence in Dental Prosthetics
Suite 2/9 Church Street
HAWTHORN VIC 3122
Telephone: (03) 9852 9969
Facsimile: (03) 9852 9469
Email: diane.woolcock@adpa.com.au
Web: www.adpa.com.au
Graduate Membership Application
I, the undersigned, hereby apply for graduate membership of the Australian Dental Prosthetists
Association (Victoria) and in so doing, agree to be bound by its Constitution and Code of Ethics
PLEASE PRINT CLEARLY AND COMPLETE FULLY
This information will form the basis of the Association’s database
Name of Member: _________________________________________________________________________________
Birth Date: ______ / ______ / ______
DBA Registration No. _________________________
Home Address of Member: _________________________________________________________________________
_____________________________________________________________________
Phone: _____________________
Name of Business / Company: _____________________________________________________________________
Business address: ___________________________________________________________________________________
_____________________________________________________________________
Fax Number: ___________________________________
Phone: _____________________
Mobile Number: _________________________________
Email address: _____________________________________________________________________________________
Year of Qualification: _____________ Training Institute: _______________________________________________
Signature_____________________________________________Date___________________________________
One [1] Year Free - Full Membership [Graduate]: from date of graduation.