2019 Bursary Application Form

Step 1 of 8

  1. Section 1: Personal & Practice Details

  2. Application details

  3. *
    Please enter your title
  4. *
    Please enter your first name
  5. *
    Please enter your surname
  6. *
    Please enter your membership number
  7. Practice details

  8. *
    Please enter your practice name
  9. *
    Please enter your address
  10. *
    Please enter your suburb
  11. *
    Please make a selection
  12. *
    Please enter your postcode
  13. *
    Please enter your phone number
  14. *
    Please enter your email address
  1. Section 2: Practice CPD Plan

  2. Please provide the details about the following:

  3. 1. Your type of practice, its values and your dental team.

    List the profiles of everyone in your dental team with their position titles and describe how each member supports the values of the practice - include both full time and part time staff.

  4. *
    Please enter details
  1. 2. The community the practice serves and the general needs of patients.

    Describe the demographics of the community, patient types and how the practice caters to patient needs.

  2. *
    Please enter details
  1. 3. The potential courses/programs/workshops the bursary will be applied to for everyone in the practice team.

    Describe the practice’s commitment to continuing professional development and learning for the dental team, and a list of courses, together with the reasons they were chosen.

  2. *
    Please enter details
  1. 4. The benefits of the bursary for the practice team.

    Describe how the amount of the bursary will impact on the dental team.

  2. *
    Please enter details
  1. 5. The benefits of the bursary to your patients.

    Describe how the bursary will help to improve the practice’s services to patients. You could also include the practice’s involvement in the promotion of oral health to patients and the community.

  2. *
    Please enter details
  1. Section 3: CPD Log

  2. This application requires all dental practitioners* in the practice to attach one copy of their individual log of CPD activities undertaken in the last two years (from December 2016 onwards).

    * This applies to those who are registered with the Australian Health Practitioner Regulation Agency (AHPRA) and the Dental Board of Australia (DBA).

    Please submit ONE individual log of activities for each dental practitioner. PDF files are preferred

  3. *
    Please make a selection
  4. *
    Please attach file
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    Please attach file
  6. *
    Please attach file
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    Please attach file
  8. *
    Please attach file
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    Please attach file
  10. *
    Please attach file
  11. *
    Please attach file
  12. *
    Please attach file
  13. *
    Please attach file
  1. Section 4: Declaration

  2. I declare that:

    1. To the best of my knowledge the information supplied in this application is accurate and correct.
    2. The practice is committed to active participation in professional development and training for everyone in the practice.
    3. Practice staff consent to being profiled in ADAVB and BOQ Specialist communications to the dental community.
  3. *
    Please accept the declaration