Undergraduate Placement Application Form

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Undergraduate Placement Application Form

Important Information:

This program is limited to final year dental students studying a Bachelor of Dental Science.
Only students enrolled in Australian universities and countries that have reciprocal practise rights (NZ, UK, Republic of Ireland and Canada) are eligible to apply.
Placements are limited to clinical observation only.
Areas and departments of observation are at the discretion of DHSV and are subject to change due to operational requirements.
Placements cannot exceed 5 days.
Placements are limited to weekdays.

Explanatory Notes:

Your Application Form should be accompanied by the additional documents referred to in Section D.
Answer each question on this Application Form.
Where a question can be answered by marking a box, place an X in the box.

Section A - APPLICANT DETAILS

Name

Title

Surname

First Given Name

Second Given Name

Date of birth

(DD/MM/YYYY)

Address

Number and Street Name

Town / Suburb

State / Territory

Postcode

Country

Contact Details

Telephone Number

Mobile Number

University E-mail Address

Personal E-mail Address

Section B - EDUCATION DETAILS

Tertiary Education

University currently enrolled at

Course Name

Year Commenced

Anticipated date of completion

Section C - PLACEMENT DETAILS

Number of days requested

Days

Preferred Date for Placement

Option 1

From (DD/MM/YYYY)

To (DD/MM/YYYY)

Option 2

From (DD/MM/YYYY)

To (DD/MM/YYYY)

Section D - ADDITIONAL INFORMATION REQUIRED

The following additional information is required as part of your application for the placement. Please attach these documents below:

Enrolment Confirmation

Current university examination results

Curriculum Vitae

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

Administration Support Officer – Planning & Recruitment
Dental Health Services Victoria
PO Box 1273L
Melbourne Victoria 3001
AUSTRALIA

Section E – DECLARATION

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

Please note: submission of this form may take up to 30 seconds. Please only click the Submit button once.

Verification: