Dental Practitioner Graduate Program Application Form

Please fill out the below form to apply for the Dental Practitioner Graduate Program.

Section A - APPLICANT DETAILS

Name

Title

Surname

First Given Name

Second Given Name

Date of Birth

DD/MM/YYYY

Home Address

Street

Town / Suburb

State / Territory

Postcode

Telephone Number

Mobile Number

E-mail Address

Citizenship

Are you an Australian citizen or permanent resident of Australia?

	Yes
	No

If yes - A certified copy of your birth certificate, naturalisation or other official documents such as passport will be asked for should you be selected to join the Dental Practitioner Graduate Program.

If no - You are not eligible to apply.

Aboriginal / Torres Strait Islander

Do you identify yourself as

	Aboriginal
	Torres Strait Islander

Other Information

Have you previously or are you currently receiving funding from a Scholarship or Grant program?

	Yes
	No

If Yes - Name of Scholarship / Grant

Duration of Funding - From

Amount $

Section B - EDUCATION DETAILS

Current Tertiary Education

University currently enrolled at

Course name

Year Commenced

Length of Course

	Full Time
	Part Time

Anticipated Date of Completion

Section C - REFEREES

Please provide the name, address and contact phone number of two clinical referees.

1. Referee

Full Name

Address

Contact Number

2. Referee

Full Name

Address

Contact Number

Section D - ADDITIONAL INFORMATION REQUIRED

Applications must be accompanied by:

• Covering letter outlining why you would benefit from the Dental Practitioner Graduate Program
• Curriculum Vitae
• Current university examination results
• A letter of Manager approval if currently employed at a public dental clinic

Cover letter

Curriculum Vitae

Current university examination results

Manager Approval Letter

If you are unable to attach any of the above documents, complete this application and forward to:

Administration Support Officer – Planning and Recruitment
Dental Health Services Victoria
PO Box 1273L
MELBOURNE VIC 3001

Note: Please mark "Dental Practitioner Graduate Program ".

Section E – DECLARATION

I declare that the information supplied by me in this application is true and correct in every particular.

I authorise the Dental Health Services Victoria to seek details from the tertiary institution at which I am enrolled, including details of enrolment variations, academic record, examination results, attendance and any other matter pertaining to my eligibility to apply for the Dental Practitioner Graduate Program.

I agree with the above statements

	Yes
	No

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Dental Health Services Victoria

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Dental Practitioner Graduate Program Application Form