Branch Application

Please fill out all the form sections and we will be in touch as soon as we can. Please ensure that your two nominators are aware and happy to be nominators (we may need to contact them). Thank you.

Name

First Name

Last Name

Cell Phone Number

Qualifications

Year of BDS Graduation

Practising Address

Mailing Address

Nominated By

We require that two Branch Members nominate you to join.

Nominator #1

First Name

Last Name

Nominator #2

First Name

Last Name

Confirmation

By joining the Branch (if elected) you will promote the objects and interests of the Association, and will abide by the Rules of the Association. As long as you continue to be a member of the branch you will pay the subscription required once you are notified of admission as a member. You also must be a financial member of the New Zealand Dental Association (Inc). You agree to be contacted about branch matters via email and/or SMS.

I confirm the above