OFFICE USE ONLY

Date Received:

Reference Number:

Receipt Number:

1254

Australian Dental Council

Application for Assessment of Professional Qualifications in Dentistry

ABN 70 072 269 900

Make sure you provide all the documents required and sign the declaration on the last page. When filling in this form, please print clearly in English using CAPITAL LETTERS. Note: This is not an application to sit for an examination.

Use this information to help you complete the application form.

Please read the accompanying explanatory notes before completing this form.

Section A

Personal details

All applicants must complete this section. Attach three passport-size photographs of yourself here. The photograph must be less than three months old. 1 Name as shown in passport Family/last name(s)

AS-1 V4

Given/first name(s)

2 3

Preferred title Mr

Mrs

Ms

Miss

other (please specify)

Other names you are known by or have ever been known by Family/last name(s) Given/first name(s)

For more information about answering this question, see the accompanying notes.

Gender

Male

Female

Date of birth

DD

MM

YY

Country of birth

7 Country of permanent residence

8 Are you resident in Australia? Yes

No

In which state or territory of Australia do you intend to live?

Section B

Contact details

All applicants must complete this section. 9 Address for correspondence Agents name (if applicable)

For more information about answering this question, see the accompanying notes.

Your address (or agents if applicable)

Telephone Email Address

Fax

10 If you have given the name and address of an agent at Question 9, do you authorise that agent to act on your behalf? Yes No Not applicable

Section C

Your professional education

All applicants must complete this section. Give details of the undergraduate dentistry course you have completed. 11 What is the name of the undergraduate qualification that you have obtained? In English In your own language

Name of dental school

Name of institution/university

Full address of institution

What was the normal entry requirement for the course?

Normal length of full time course What was the length of time it took you to complete the course?

Years

Date course commenced

DD

MM

YY

Date course completed

DD

MM

YY

If there was any interruption to your study, provide reason here:

Years

Was a period of compulsory clinical experience (ie Internship) a requirement of the course?

No

Yes

What was the length of time involved?

Years

Section C
In English

Your professional education continued

In your own language

12 What is the name of any postgraduate qualification that you have obtained?

Name of institution

Full address of institution

Normal length of full time course

Years

Date course commenced

DD

MM

YY

Date course completed

DD

MM

YY

Section D
13

Dental Registration/License

All applicants must complete this section. What is the name of the registering dental authority of first registration?

What was the date of first registration? 14

DD

MM

YY

What is the name and country of the registering dental authority that granted your last registration?

What was the date of current registration? 15 Have you ever been refused a license or registration, or had a licence or registration withdrawn?

DD

MM

YY

No

Yes

Give reason

Section E

Work Experience

All applicants must complete this section. 16 Provide a summary of your professional employment experience since graduation. (Start with most recent first.) You must attach
evidence from each employer, on letterhead, showing your dates of employment. If self-employed, attach appropriate evidence (eg tax/accountants/practice records) for the required period.
Date from (DD/MM/YY) Date to (DD/MM/YY) Name of employer Country Job Title

/ / / / / / / /

/ / / / / / / /

/ / / / / / / /

/ / / / / / / /

Application checklist
Office Use Only

Section F

Paying your application fee

AUD

Assessment Fee Payable $

Information and documents you must supply I have completed and signed the application form I have provided my application fee I have attached three recent passport-size photographs

Please refer to the current Schedule of Fees at http://www.adc.org.au/fees.pdf Applications with the incorrect fee will not be processed.

Payment can be made by bank cheque, Australian Money Order, Visa or Mastercard. Cheques/money orders must be made payable in Australian Dollars to the Australian Dental Council. 17 Please select your method of payment: Bank cheque (enclosed) Money Order (enclosed) Credit Card (choose one and complete details) Visa Mastercard
Name of cardholder

I have provided original certified copies of: Identification The relevant pages of my passport Evidence of change of name (where applicable) Professional Education Undergraduate degree certificate Academic transcripts Evidence of Internship (where applicable) English translations of the above documents (where applicable) Dental Registration/License Original registration/license to practice from graduation Current registration/license to practice Letter of Good Standing (if current registration was issued more than 12 months ago) English translations of the above documents (where applicable) Work Experience Evidence of my work experience as a dentist from graduation to present Two written references from employers or, if you were self-employed, from colleagues

Card number

Expiry Date M M Y Y

Amount $ AUD

Signature of cardholder

Send your completed application to:

Australian Dental Council Ground Floor, 120 Jolimont Road East Melbourne VIC 3002 AUSTRALIA

Section G

Declaration

You must read and sign this declaration. 18 I declare that: The information I have supplied on this form and any attachments is complete, correct and up-to-date I am not subject to any professional disciplinary/legal proceedings past or pending I undertake to inform the Australian Dental Council (ADC) of any changes to my circumstances (eg name, address) while my application is being considered I have read the explanatory notes and authorise the Australian Dental Council (ADC) to make any enquiries necessary to assist in the assessment of my qualifications. Date
DD MM YY

Signature

Application for Assessment

Of Professional Qualifications in Dentistry
Introduction If you are an overseas trained dentist who intends to migrate and work as a dentist in Australia, you should first contact the nearest Australian Embassy, High Commission or consulate for information about migration procedures and requirements for assessment of your qualifications. Information relevant to the general skilled migration categories is available from Australian overseas posts. If you are already in Australia on a temporary basis but need a skills assessment to support an application to change your immigration status to Australian resident, you should seek the advice of the Department of Immigration in your state or territory. Change of Name Any change in name will need to be supported by official documentation. The ADC does not accept Affidavits/Statutory Declarations. Agents The ADC normally deals directly with applicants seeking an assessment of their overseas qualifications. 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 such as a solicitor, family member or other agent to deal with the ADC on your behalf, you will need to indicate this at Question 10. Certification It is essential that copies of documents are certified. Each copy must be clearly authorised as a true copy of the original by an appropriate person. Documents can be certified by a Justice of the Peace (JP), Notary Public, Commissioner for Affidavits, Magistrate, Australian Post Master or an Officer of an Australian High Commission or Embassy. To have your copies certified you will need to present both the original and copy of each document to the person certifying the copies. Each copy of the document must be certified separately and must show clearly: the words certified true copy of the original the original signature of the certifying officer and the name and address or provider/registration number (where applicable) of the certifying officer legibly printed below the signature. It must be possible, from the details provided, for the ADC to contact the certifying officer if necessary. References You will need to provide two recent (dated) written professional references attesting to your competence and good standing as a dentist, from employers, supervisors or tutors or, if you were selfemployed, from professional colleagues. References must: be written on the official letterhead of the person, company or government department providing the reference indicate clearly on the letterhead the full address of the person or company, any telephone and fax numbers, and email and website addresses have the name and position of the person who signs the reference typed or stamped below that person's signature. A reference with an illegible signature will not be accepted include the direct contact number of the person writing the reference. Please note the ADC will not accept professional references from family members.

About the information you provide

The information on the Application form is collected by the Australian Dental Council (ADC) for the purposes of assessing overseas qualifications in dentistry and establishing your eligibility to enter the professional examination process. All personal information will be handled in accordance with the Privacy Act. Details may be verified with or provided to other agencies where necessary or required by law. Documents you must include To support your application, you will need to provide certified copies of all documents listed in the Checklist section of the application form. Certified copies of the following documents must be submitted: 1. Degree, diploma or certificate in original language. Applicants with Chinese qualifications will also need to arrange verification of their dentistry degree through VETASSESS by emailing [email protected] or phoning +61 3 9655 4800. VETASSESS must send its report directly to the ADC. Official transcripts of educational courses completed showing subjects, hours, examination results and details of practical and clinical education, in original language. Evidence of internship where applicable. First registration/licensure. Please note the ADC does not accept temporary, provisional or limited registration. You must be able to show registration from graduation. Current registration. A letter of good standing is also required if your last registration was issued more than 12 months ago. Evidence of employment experience as a dentist from graduation to date of application. Two recent written references relating to professional competence. Evidence of change of name where applicable. The relevant pages of your passport.

2.

3. 4.

5. 6. 7. 8. 9.

Certified translations in English of all documents must be provided and attached to the document/s to which they refer. The ADC reserves the right to request applicants provide translation completed by a translator accredited by the National Accreditation Authority for Translators and Interpreters (NAATI). Level 3 accreditation is normally required. Other documents we may need Sometimes we may ask for additional documents or information where insufficient evidence has been provided. What you shouldnt send All of the documents required for the assessment of your qualifications are included in the Checklist. Do not send additional documents such as secondary school or postgraduate results, continuing professional education certificates or your undergraduate syllabus. Please note any original documents submitted to the ADC will not be returned to you. Processing your application Applications are processed strictly in order of receipt. Once your eligibility to undertake the ADC examination process has been established, you will be sent an application to sit the Preliminary Examination.