RDHM Dentist Internship Program Application Form

Please fill out the below form to apply for the RDHM Dentist Internship 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 receive a Internship.

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 an Internship at RDHM
• Curriculum Vitae
• Statement of University results

Cover letter

Curriculum Vitae

Statement of University results

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 "RDHM Dentist Internship Program Application".

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 RDHM Dentist Internship Program.

I agree with the above statements

	Yes
	No

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Dental Health Services Victoria

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RDHM Dentist Internship Program Application Form