Login Home Student Support Forms & Documents Current: Doctor of Clinical Dentistry Doctor of Clinical Dentistry Application: Additional information form Personal details Title - Select -MissMsMrMrsDr Surname Given name(s) in full Previously or currently a Staff member, Student or Visitor at the University? Yes No University of Adelaide ID Date of birth Identified gender - Select -MaleFemalePrefer not to say Email address Home street address Suburb State Postcode Is your postal address the same as your home address? Yes No Postal street address Suburb State Postcode Mobile phone number Home phone number Residency status - Select -Australian CitizenPermanent Humanitarian VisaOffshore InternationalPermanent ResidentNew Zealand CitizenTemporary ResidentUnknown ATSI status - Select -AboriginalTorres Strait IslanderNone of the above Further information Area of specialisation - Select -EndodonticsOrthodonticsPeriodonticsProsthodonticsSpecial Needs Dentistry Please provide a half page description of your research interests and aptitudes Qualifications Information message Complete certified transcripts of degrees and diplomas must be attached, unless your qualifications are from the University of Adelaide. Photocopies must be officially certified as true copies of the original documents. Documents in a language other than English must be officially certified as true copies of the original documents and must be accompanied by a certified copy of the English translation. If qualifications were awarded in a different name, please provide evidence of name change. Academic qualifications Re-order Name of qualification Institution attended Completion date Upload transcripts Weight Operations Name of qualification Institution attended Completion date Or years when enrolled if incomplete. Upload transcripts Complete certified transcripts of degrees or diplomas.Unlimited number of files can be uploaded to this field.20 MB limit.Allowed types: doc, docx, rtf, pdf, txt, ppt, pptx, xls, xlsx, jpg, png. Item weight Add more items more items Professional qualifications Re-order Qualification Year awarded Certified evidence of professional qualification Weight Operations Qualification Year awarded Certified evidence of professional qualification One file only.20 MB limit.Allowed types: doc, docx, rtf, pdf, txt, ppt, pptx, xls, xlsx, jpg, png. Item weight Add more items more items Non-award study Formal non post-secondary enrolments not completed as part of a degree program. Re-order Non-award course Year awarded Weight Operations Non-award course Year awarded Item weight Add more items more items Employment Please provide details and evidence that you have two years of experience in general dental practice. (Registration certificates, CV and referees, and/or other appropriate documentation can be attached below). Place of current employment Position held Employment address Please upload a current copy of your CV Include full employment history and publications. One file only.20 MB limit.Allowed types: doc, docx, rtf, pdf, txt, ppt, pptx, xls, xlsx, jpg, png. Referees Please provide contact details of 2 employment and/or academic referees. Please note that these referees will be contacted in due course. Referee information Full name Position Company Telephone Email address Address Operations Full name Position Company Telephone Business hours Email address Address Full name Position Company Telephone Business hours Email address Address Supporting documentation Please include supporting documentation if required (E.g. Evidence of name change, registration certificates, etc.) One file only.20 MB limit.Allowed types: doc, docx, rtf, pdf, txt, ppt, pptx, xls, xlsx, jpg, png, zip. Declaration Information message I certify that to the best of my knowledge all documentation and information submitted or made available by me in connection with this application is true, accurate and complete. I acknowledge that the provision of inaccurate or incomplete information may result in the withdrawal of any offer of enrolment or the cancellation of any enrolment allowed on the basis of acceptance of that offer. I consent to the collection, storage and disclosure of information relating to record falsification or other irregular acts in accordance with Universities Australia procedures. I authorise the University of Adelaide to obtain my academic record from other educational institutions. If sponsored I authorise the University of Adelaide to release details of my academic progress to my sponsoring body upon request. I understand: That the University of Adelaide is collecting information on this form for the purposes of assessing my eligibility for admission to the Program and allocation of a Commonwealth Higher Education Student Support Number (CHESSN) to me; The University of Adelaide will disclose this information to the Department of Education and Training (DET) for those purposes; DET will store this information securely in the Higher Education Information Management System; DET may disclose the information to the Tax Office; and The University of Adelaide and DET will not otherwise disclose this information without my consent unless required or authorised by law. I agree to the declaration above
