Application for Membership of the Auckland Dental Association

MEMBERSHIP PROCESS: You must be a current NZDA member to be eligible for ADA membership. Please complete and submit the below application form. We look forward to welcoming you to the Auckland Dental Association.

Title(*)

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Surname(*)

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Preferred First Name(*)

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Your Initials(*)

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Date Of Birth(*)

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format: dd-mm-yyyy

Sex (Select One)(*)

MaleFemale Invalid Input

Year Of Graduation(*)

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Year Of Registration(*)

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NZDA Member Number(*)

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Role Description(*)

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i.e. Dental Surgeon, Oral Surgeon, Endodontist

Qualifications(*)

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Personal Details

Home Address(*)

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Languages Spoken(*)

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Personal Email(*)

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Mobile(*)

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Practice Details

This information will be used to create your free listing on the ADA’s Find-a-Dentist website. Upon completion of the membership process you will be issued with ADA website log-in details.

Practice Name(*)

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Practice Address(*)

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Practice Phone(*)

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Practice Email(*)

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Practice Website(*)

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Services Offered(*)

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(i.e general dentistry, crown & bridge, cosmetic, paediatric, implants, etc)
This information is for our find-a-dentist website available to the general public by locality listing.

Contact Email(*)

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Please advise which email address you prefer to be contacted on.

Additional Practice(s) Details

Please enter any other additional practices details that you also provide your services from as applicable.

Additional Practice A

Practice Name

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Practice Address

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Practice Phone

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Practice Email

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Practice Website

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Additional Practice B

Practice Name

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Practice Address

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Practice Phone

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Practice Email

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Practice Website

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How Did You Find Out About The ADA?

Please select an option(*)

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If Other, please specify

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Application Agreement

I hereby apply for admission as a member of the Auckland Dental Association (A Branch of the NZDA) and agree to its Rules and to promote its objects and interests.

Signed(*)

Sign Above

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Date Signed(*)

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format: dd-mm-yyyy

Enter the characters displayed(*)

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