July 2013 (AS-1 v8) Page: 1 of 11

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 8010, Australia
ABN 70 072 269 900


Application for Initial Assessment of
Professional Qualification in General Dentistry

You MUST refer to the Explanatory Notes & Checklist to complete the application form.
Ensure all supporting documentation and payment as listed in the Checklist are 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 Photographic Identification

1. Please supply
one (1) certified
colour
passport-size
photograph of
yourself for the
purpose of
identification.


The photograph must not be older than three (3)
months


DO NOT ATTACH PHOTOGRAPH HERE



Section B Applicants Personal Details and Identification
2. Surname
/Family name


3. Given/first
name(s)


4. Previously
known or Other
name(s) known
by

Surname/Family Name


Given/First Name(s)
5. Date of Birth
& Sex
/ /
Day Month Year

Female Male





Office Use Only


Ref No: /

Date: Receipt #:




(Office Use Only)
AS-1 V8


July 2013 (AS-1 v8) Page: 2 of 11
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 8010, Australia
ABN 70 072 269 900


Section C Applicants Personal Contact Details

6. Contact details
for applicant
only.




Address

City

State/Territory Area/Postcode

Country

Telephone

Email Address

Section D Authority to Act
(if you nomination of a person or agent to act on your behalf)
7. 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: Yes No


Section E Primary Dentistry Education Details

8. Title of
Qualification


9. Name of the
institution
/University

10. Address of the
institution
/University


Address


City

State/Territory Area/Postcode

Country
11. Length of your
primary
dentistry course
Years ________ Months________
Was this the normal length of your course? Yes No
Was this a full time course? Yes No
12. In which
country did you





July 2013 (AS-1 v8) Page: 3 of 11
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 8010, Australia
ABN 70 072 269 900

obtain your
primary
dentistry
qualification?
Tick the box of the country in which you obtained your primary qualification in
dentistry:
Australia
Canada
New Zealand
Republic of Ireland
South Africa
United Kingdom
United States of America
Other (please state) __________________________________
___________________________________________________
13. Language of
primary
dentistry course
Was your primary dentistry course in English?
Yes No (please state) __________________________________

14. Course dates

Date Commenced: / / Date Completed: / /
Day Month Year Day Month Year
15. Internship
dates
(if applicable)

Date Commenced: / / Date Completed: / /
Day Month Year Day Month Year
Section F Secondary (High School) Education Details

16. Name of your
Secondary
School


17. In which
country did your
Secondary
Education take
place?
Tick the box of the relevant country:
Australia
Canada
New Zealand
Republic of Ireland
South Africa
United Kingdom
United States of America
Other (please state) __________________________________
___________________________________________________



July 2013 (AS-1 v8) Page: 4 of 11
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 8010, Australia
ABN 70 072 269 900

18. Length of your
Secondary
Education

Years ______ Months______
Did you complete your Secondary Schooling? Yes No
19. Language of
Secondary
Education
Was your Secondary Schooling in English?
Yes No (please state) __________________________________
20. Secondary
Education dates

Date Commenced: / / Date Completed: / /
Day Month Year Day Month Year

Section G Registration/Licence History

21. Name of your
first
Registration/
Licence
Authority


22. Date of first
Registration/
Licence
/ /
Day Month Year
23. Name of your
current or most
recent
Registration/
Licence
Authority


24. Expiry date of
current or most
recent
Registration/
Licence
/ /
Day Month Year
25. Registration/
Licence status Have you ever been refused registration/licence? *Yes No
Have you ever had you registration/licence withdrawn? *Yes No
Are you subject to any professional disciplinary/ *Yes No
legal proceedings past or pending?
(* If Yes please provide a signed written explanation)
26. Letter of Good
Standing
(this document
can not be
submitted by
applicants)
The Australian Dental Council requires an original Letter/Certificate of Good Standing
to be forward directly from the previous or most recent registration/licence authority
to the Australian Dental Council.
Yes, I have requested a Letter/Certificate of Good Standing to be
provided to the ADC.
(This document will not be accepted if it is provided by the applicant. It must be
provided directly to the Australian Dental Council by the registration/licence authority)




July 2013 (AS-1 v8) Page: 5 of 11
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 8010, Australia
ABN 70 072 269 900

Section H Employment History

27. Recency of
Practice
Have you worked as a registered dentist in the last 5 years?
Yes - Please complete the following employment details for each
employer.
No - Please submit a signed written statement explaining why you
have not worked in the 5+ years.
(If you are or have been self employed please state and provide details below please
refer to the Explanatory Notes & Checklist)

Name of the
Employer #1

State, Territory and
Country

Your Position

Dates of
Employment

Date Commenced: / / Date Completed: / /

Name of the
Employer #2

State, Territory and
Country

Your Position

Dates of
Employment

Date Commenced: / / Date Completed: / /

Name of the
Employer #3

State, Territory and
Country

Your Position

Dates of
Employment

Date Commenced: / / Date Completed: / /


Section I Professional References

28. Professional
References
The Australian Dental Council requires two recent written professional references
attesting to competence and good standing as a dentist, from employers, supervisors
or tutors; and if you were self-employed from professional colleagues.
Reference #1 (name) ____________________________________________
Reference #1 (name) ____________________________________________





July 2013 (AS-1 v8) Page: 6 of 11
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 8010, Australia
ABN 70 072 269 900

Section J Declaration

Please read and ensure you understand the following declaration before signing:
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 practice as a dentist
or otherwise regarding matters relevant to this application.
I undertake to inform the Australian Dental Council of any changes to my circumstances or details.
I am not subject to any professional disciplinary/legal proceedings past or pending, except as
otherwise specified in Section G.
I have read the explanatory notes and authorise the Australian Dental Council to make any
inquiries necessary to assist in the assessment of my application.
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
assessment of this application or refusal of this application.
I understand that the Australian Dental Council reserves the right to require further
documentation to progress the assessment of this application.
I am the person named in this application and all attached documents.
The above statements, information provided on my application form and all documentation
provided with this application are true and correct.

Signature of Applicant _______ _______________________________________________________

Date: / /
Day Month Year

You MUST refer to the Explanatory Notes & Checklist to complete the application form.
Ensure all supporting documentation and payment as listed in the Checklist are 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







July 2013 (AS-1 v8) Page: 7 of 11
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 8010, Australia
ABN 70 072 269 900


Section K Payment

Initial Assessment of Professional Qualification in General Dentistry Fee Payable

Applications will not be assessed until the assessment 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.


Credit Card Type (please tick)

Visa MasterCard

I, authorise the Australian Dental Council to deduct from
my credit card the assessment fee of $................... (AUD)

Name of cardholder




Card number



Expiry Date

M M Y Y


Signature of cardholder




Post your completed application form together with your supporting documentation
and application fee to:
Australian Dental Council
PO Box 13278
Law Courts,
Victoria 8010
Australia





July 2013 (AS-1 v8) Page: 8 of 11
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 8010, Australia
ABN 70 072 269 900

Explanatory Notes & Checklist

Explanatory Notes

Introduction
The first step in the Australian Dental Council pathway is the assessment of the qualified dentists primary
professional qualification in dentistry.

The Australian Dental Council (ADC) assesses your professional qualification in dentistry, work experience,
registration/licensure history, good standing and other matters to establish your eligibility to proceed with
the examinations. This assessment is based on the information you provide in this Application. Overseas
qualified dentists may be eligible to undertake the ADC examination pathway if they hold a university dental
degree which was obtained after at least four years' full-time academic study at an acknowledged university
and they hold registration/licensure as a dentist in their country of training or practice and there has been
no withdrawal of registration or refusal to register.

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.

The assessment of your application may take up to 6 weeks from the date your application is received. A
complete application includes all the required documentation which has been correctly certified.

You will be notified in writing if we need any additional information to process your application. Incomplete
applications will result in assessment delays and applicants will be notified in writing. Your application will be
valid for one (1) year from initial receipt. Should your application remain incomplete at the end of this one
(1) year time frame, you will be required to reapply.

You will be notified in writing of the outcome of the Assessment and the next steps in the process.

Please note:
To prevent delays in assessment of your application please read the application form (including the
Explanatory Notes & Checklist) carefully and ensure you have provided all the relevant supporting
documentation and that the documents provided are correctly certified
Please refer to the Australian Dental Councils certification guidelines which can be downloaded from the
ADC website at www.adc.org.au

Immigration Information
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 these 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 (http://www.immi.gov.au/contacts/).

Other documents we may need
Sometimes we may ask for additional documents or information where insufficient evidence has been
provided.







July 2013 (AS-1 v8) Page: 9 of 11
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 8010, Australia
ABN 70 072 269 900


What you should not send
All of the documents required for the assessment of your qualifications are included in the Checklist.
Do not send additional documents such as any specialty course results, continuing professional education
certificates or your primary qualification course syllabus.

Identity/Change of Name
Applicants must state their full legally registered name. Any change in name will need to be supported by
official documentation showing the link with previous names (eg before and after marriage). The ADC does
not accept Affidavits/Statutory Declarations for this purpose.

Certification
It is essential that copies of documents are certified. Each copy must be clearly certified by an appropriate
person as a true copy of the original. Please refer to the Australian Dental Councils certification guidelines
which can be downloaded from the ADC website at www.adc.org.au.

Any original documents submitted to the ADC will not be returned to you.

Translation of Documents
Certified translations in English of all non-English documents must be provided and attached to the
document/s to which they refer. The ADC reserves the right to request that applicants provide translation
completed by a translator accredited by the National Accreditation Authority for Translators and Interpreters
(NAATI). Level 3 accreditation is normally required.
Please note:
The translators details (name, address, etc) must be stated in English
Certification statements on translated documents must be translated in English.

Applicants Personal Contact Details
ALL applicants must complete Section C of this application to ensure accurate information is provided for
future use.

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 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 Australian Dental Councils Authority to Act form which can be downloaded from the
ADC website at www.adc.org.au

Professional 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 self-employed, from
professional colleagues. The ADC will not accept professional references from family members.



July 2013 (AS-1 v8) Page: 10 of 11
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 8010, Australia
ABN 70 072 269 900



Checklist

Section A
Photographic
Identification
Please supply one (1) certified colour passport-size photographs of
yourself for the purpose of identification.
Section B
Applicants Personal
Details and
Identification
Certified copy of current passport - relevant pages.

Certified copy of evidence of change of name documentation where
applicable.
Section C
Applicants Contact
Details
All details completed. (no supporting documents required)

Section D
Authority to
Act/Agent
(If applicable) Authority to Act form
Section E
Primary Dentistry
Education Details
Certified copy of degree, diploma or certificate in original language.
Certified copy of an official transcript of your primary dentistry
education course completed in original language. Transcript MUST
state:
Applicants name
Subjects
Theory total hours
Clinical total hours
Course start and completion dates
Language in which course was taught
Examination results and details.
Certified copy of evidence of internship where applicable.

Section F
Secondary Education
Details
Certified copy of evidence may include but is not limited to a school
leaving certificate or a Year 12 certificate:
name and location of the secondary education provider
the years in which an applicant undertook their secondary
education at this location
the final year of secondary education completed
Language in which secondary education was taught.
Section G
Registration History
Certified copy of first registration certificate/licence
Certified copy of current registration certificate/licence
Request a Letter/Certificate of Good Standing to be forwarded
DIRECTLY to the Australian Dental Council.
Applicant cannot submit this document.





July 2013 (AS-1 v8) Page: 11 of 11
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 8010, Australia
ABN 70 072 269 900

Section H
Employment History

Certified copy of official work statement must contain the following
information from each of your employers:
On official letter head (including full address and contact
business details)
Date issued
Applicants name in full
Employment start and finish dates
Confirms the applicant was employed as a registered dentist
Signed by a recognised Manager/Director

Or if Self-employed

Certified copy of appropriate evidence, eg tax documents, accountant
business records, practice records, business registration certificate

Or if not employed in the past five years
(If applicable) a signed written statement explaining why you
have not worked in the last 5 years

Section I
Professional
References
Original or certified copies of two recent (dated) written professional
references containing the following information:
On official letter head of the person, company or government
department providing the reference (including full address and
contact business details)
Date issued
Applicants name in full
Attesting to your competence and good standing as a dentist
Signed by employer, supervisor or tutor or, if you were self-
employed, from professional colleagues.

Section J
Declaration
Signed and dated (no supporting documents required)

Section K
Payment
All Payment details completed and/or enclosed.


Post your completed application form together with your supporting
documentation and application fee to:
Australian Dental Council
PO Box 13278
Law Courts,
Victoria 8010
Australia