Please note: All information in this form is collected and will be used and disclosed in accordance with applicable laws.

Step 1: Applicant Information

Demographics

First Name:

Last Name:

Middle Name(s):

Previous Name(s):

Preferred Name:

Date of Birth:

Gender:

Personal Email:

Business Email:

Home Phone:

Mobile Phone:

Initial Province of Employment:

Initial Employment Year:

Passport-style Photo:

Character References (Download)

Home Mailing Address

Mailing Address

Address Line 1:

Address Line 2:

City:

Province:

Postal Code:

Country:

Education

Denturism Graduating Institution:

(Other Institution, Name and Address):

Year Graduated:

Diploma:

Transcripts:

Additional Education

Other Degree/Diploma:

School of Graduation:

Year of Graduation:

Declarations

I understand that I may be required to submit further information to determine eligibility for membership.

I understand that the collection, use and disclosure of my personal information will be handled in accordance with applicable privacy policies and laws.

I will immediately advise the College, in writing, if there is any change to any of the information contained in this application.

I verify that all information contained in this application, including these declarations, is complete and accurate. I understand that a false or misleading statement, an omission or misrepresentation may have impact on the validity of this application.

Fees & Payment Information

Details

Payments are accepted by credit card, email transfer or cheque.

You will be contacted by the College with more information.

Student Membership Fee *:

$150

Subtotal:

$150

GST:

$7.5

Total:

$157.5

* Non-refundable

Spam Filter:

Captcha Required

Please review your application information thoroughly before submitting. When ready, please submit by clicking on the button below.