App - Written Examination Dentist
App - Written Examination Dentist
App - Written Examination Dentist
Written Examination
Application - Dentist
Ref No:
WE-1 V10
Date Paid
Receipt #:
You MUST refer to the Explanatory Notes & Checklist to complete the application form.
Ensure all supporting documentation and payment as listed in the Checklist is attached.
Please print clearly in English using CAPITAL LETTERS
Please complete this application form in black or blue pen, ensuring the declaration has been signed
and dated.
This symbol indicates supporting documentation is required as evidence of the details you have stated
in this application form. Please refer to the Explanatory Notes & Checklist
Section A
1. Please supply
one (1) certified
colour
passport-size
photograph of
yourself for the
purpose of
identification.
Section B
2. ADC Reference
number
3. Surname
/Family name
4. Given/first
name(s)
5. Previously
known or Other
name(s) known
by
6. Date of Birth
& Sex
Photographic Identification
(Office Use
Only)
Surname/Family Name
Given/First Name(s)
/
Day
/
Month
Year
Female
Male
Page: 1 of 8
Contact information
Tel + 61 3 9657 1777
Fax + 61 3 9657 1766
Website: http://www.adc.org.au
Email: [email protected]
Address: PO Box 13278, Law Courts, Victoria Australia 8010
ABN 70 072 269 900
Section C
7. Contact details
for applicant
only.
Area/Postcode
Country
Telephone
Email Address
Section D
8.
Authority to Act
(Nomination of a person or agent to act on your behalf)
If you wish to appoint a person/agent to act on your behalf for this application form
please complete and submit an Authority to Act form. I understand the Australian Dental
Council will forward ALL correspondence only to my chosen nominee.
I have attached an Authority to Act to this application:
Section E
9.
No
March 20______
Overseas Venues:
Athens
London
Harare
Johannesburg
Singapore
Buenos Aires
Australian Venues:
Adelaide
Alice Springs
Hobart
Mackay
Townsville (QLD)
Yes
10. Preferred
Venue.
September 20______
Dubai
Nairobi
Lima
Riyadh
Hong Kong
Auckland
New Delhi
Manila
Christchurch
Brisbane
Melbourne
Canberra
Perth
Darwin
Sydney
Preferred venue:
__________________________________
Second preference:
__________________________________
Page: 2 of 8
Contact information
Tel + 61 3 9657 1777
Fax + 61 3 9657 1766
Website: http://www.adc.org.au
Email: [email protected]
Address: PO Box 13278, Law Courts, Victoria Australia 8010
ABN 70 072 269 900
Section F
Declaration
Please read and ensure you understand the following declaration before signing:
I agree to be available for the examination session allocated, and failure to sit will be considered a
withdrawal according to the ADC Withdrawal process.
I accept the enclosed examination fee is non-refundable in the event of failure. I also understand
that if I withdraw from the examination a penalty will be incurred. (Refer to the ADC Withdrawal
process.)
I undertake to inform the Australian Dental Council of any changes to my circumstances or details.
I have read the explanatory notes for this application form, and understand all the requirements of
applying for this examination.
I acknowledge that the Australian Dental Council may verify documents provided in support of this
application as evidence of my identity.
I understand that failure to complete all relevant sections of this application form, including
payment of the application fee and all supporting documentation, may result in delaying the
processing of this application or refusal of this application.
I understand that the Australian Dental Council reserves the right to require further
documentation in order to progress this application.
The above statements, information provided on my application form and all documentation
provided with this application are true and correct.
I consent to the Australian Dental Council making inquiries and/or exchanging information with the
authorities of any Australian state or territory, or other country, regarding my qualifications and/or
practice as a dentist or otherwise regarding matters relevant to this application.
Date:
/
Day
/
Month
Year
Page: 3 of 8
Contact information
Tel + 61 3 9657 1777
Fax + 61 3 9657 1766
Website: http://www.adc.org.au
Email: [email protected]
Address: PO Box 13278, Law Courts, Victoria Australia 8010
ABN 70 072 269 900
Section G
Payment
Written Examination Fee Payable
Applications will not be processed until the Written Examination fee has been paid in full. A receipt will be issued
upon clearance of payment. Please refer to the current schedule of fees at http://www.adc.org.au/fees.pdf .
Bank Cheque or Australian Money Order payments:
Bank cheque
Money order
Payment made by Bank cheque or Australian Money Order MUST be made in Australian dollars only.
Please note that we are unable to accept cheques from the Bank of India.
MasterCard
Card number
Expiry Date
M
Signature of cardholder
Page: 4 of 8
Contact information
Tel + 61 3 9657 1777
Fax + 61 3 9657 1766
Website: http://www.adc.org.au
Email: [email protected]
Address: PO Box 13278, Law Courts, Victoria Australia 8010
ABN 70 072 269 900
Page: 5 of 8
Contact information
Tel + 61 3 9657 1777
Fax + 61 3 9657 1766
Website: http://www.adc.org.au
Email: [email protected]
Address: PO Box 13278, Law Courts, Victoria Australia 8010
ABN 70 072 269 900
Identity/Change of Name
Applicants must state their full legally registered name exactly as it appears on your passport. Any change
in name will need to be supported by official documentation showing the link with previous names (e.g.
before and after marriage). The ADC does not accept Affidavits/Statutory Declarations for this purpose.
Applicants Personal Contact Details
ALL candidates must complete Section C of this application to ensure accurate information is provided for
future use.
It is the candidates responsibility to advise the ADC of any change of contact details. Re-issuing of
documentation/correspondence will occur an administrative fee.
Please note:
The ADC is not able to update any change of address between Written Examination Closing Dates and the
exam date. You will need to ensure all correspondence is forwarded to your updated address. If you change
your address it is your responsibility to make necessary arrangements for the redirection of your mail.
Agents
The ADC normally deals directly with applicants for the Written Examination. Australias privacy legislation
prohibits the ADC from discussing your application with other people (third parties) unless specifically
authorised to do so.
If you want someone else, such as a family member or other agent, to deal with the ADC on your behalf, you
will need to indicate this by completing the ADCs Authority to Act form. Once your Authority to Act form has
been processed all correspondence will be sent only to the person you have nominated.
Please refer to the ADCs Authority to Act form which can be downloaded from the ADC website at
www.adc.org.au
Closing Dates
Applications received by the ADC after the nominated closing dates will not be processed under any
circumstances.
The closing dates are:
14 November 2014 for the March 2015 exam
29 May 2015 for the September 2015 exam.
Exam Session
Indicate on this form which examination session you are applying for. Candidates cannot postpone an exam.
If, for any reason, you are unable to attend your nominated session, you will need to withdraw from the
exam and reapply. Please refer to the Withdrawal Policy in your Written Examination Handbook.
Examination Venue
The ADC Written Examination is held in multiple locations in Australia and overseas. The examination is
conducted in English only at all venues.
While every effort is made to accommodate a candidates venue preference, in exceptional circumstances
the requested venue may not be available and an alternative will be offered. Candidates should nominate
their preferred venue and second choice from those listed on this application form.
Please note:
All visa and travel arrangements are the responsibility of the candidate. Candidates should ensure they are
able to travel to their nominated venue at the required time.
August 2014 (WE-1 v10)
Page: 6 of 8
Contact information
Tel + 61 3 9657 1777
Fax + 61 3 9657 1766
Website: http://www.adc.org.au
Email: [email protected]
Address: PO Box 13278, Law Courts, Victoria Australia 8010
ABN 70 072 269 900
Payment
Money orders/bank cheques should be in Australian dollars, drawn against an Australian bank and made
payable to the Australian Dental Council. Personal cheques will not be accepted.
If you are paying by Visa or MasterCard, please ensure that there are sufficient funds in your account to cover
the fee transaction. The ADC will make one attempt only to process the fee payment from your nominated
credit card.
Application forms and examination fees are non-transferable.
Please use this application form as a tax invoice if required.
Withdrawal from the examination
Candidates withdrawing from an examination must do so by advising the ADC in a signed written statement.
Withdrawal statements will not be accepted by telephone.
Please refer to the Written Examination Handbook for further details.
Please note:
Failure to undertake the examination because of an inability to obtain necessary visas or to arrange
travel, etc. will be considered a withdrawal and the withdrawal process will apply.
Page: 7 of 8
Contact information
Tel + 61 3 9657 1777
Fax + 61 3 9657 1766
Website: http://www.adc.org.au
Email: [email protected]
Address: PO Box 13278, Law Courts, Victoria Australia 8010
ABN 70 072 269 900
Checklist
Section A
Photographic
Identification
Section B
Applicants Personal
Details and
Identification
Section C
Applicants Contact
Details
Section D
Authority to
Act/Agent
Section E
Exam Sessions
Section F
Declaration
Section G
Payment
Page: 8 of 8