Online Application Submission.
DrProfMrMrsMissMs
1. Surname
2. Name
3. Date of Birth
4. Mailing Address
5. Contact Number
6. Your Email
7. Education
---Under GraduateGraduatePost GraduateOther
8. Name of the Dental or Medical School you graduated
9. Healthcare profession in which you are licenced to practice. ENT, Dentist, Respiratory Physician
10. State/Country in which you are licenced to practice:
11. What % of your current practice involves treatment of Snoring/Sleep Aponea/ TMD/Bruxism:
12. Have you been convicted of a felony or comparable serious crime outside of Australia?
13. Has your license to practice ever been suspended or revoked or have you been notified of any current pending investigations related to your licence to practice?
14. How did you hear about AADSM, or who recommended that you apply for membership?
15. Additional Information
Attach additional documentation eg. Convictions, Disqualifications, Other
The file size limit: 2MB. The File format: DOC/DOCX/PDF
Your Signature
Witness Signature
Note: By pressing "Send" you agree to the following Terms and Conditions.
In making this application to the AADSM, in accordance with, and subject to its Articles of Incorporation, Bylaws and such other governing provisions as, from time to time, are in force, (hereinafter collectively referred to as its regulations), I agree to disqualification, suspension or revocation of membership and to surrender any Certificate of membership or competency of Fellowship in the event of any misstatement or misrepresentation of a material fact, any material submitted or in the event that any of the aforementioned regulations applicable to said membership or Fellowship Status are violated by me, as determined by the AADSM. I further agree to hold the AADSM, its officers, examiners, employees and agents, free from any claim, damage or liability by reason of action they or any of them may take in respect of this application, including, but not limited to, the failure of the AADSM to issue me membership, or the suspension, revocation or making of any demand for the surrender of an issued Certificate of membership or Fellowship Status or the removal of my name from any list of holders of such certificates.
In support of this application, I certify that all of the statements and/or affirmations made herein, including any statements of explanation, are true, complete and correct to the best of my knowledge and belief and are made in good faith and without mental reservations, and I agree that any false, incomplete or incorrect statements may serve as a basis for denial of my membership application, as well as disqualification, suspension or revocation of membership if already accepted.
