Full Member Application Form
Please fill in your details below and once submitted with payment please allow 10 working days for your application to be processed
Surname:
*
Maiden Name:
First Name/s:
*
Title:
Address for Correspondence:
*
Date of Birth:
*
Telephone (Home):
*
Telephone (Mobile):
Email Address:
Name of Training School:
*
Surname at time of training:
Year of Qualification:
*
GDC Registration Number:
Other Professional Qualification : Dental Nursing:
Tick all that apply
FAETC:
Cert OHE:
Cert H Ed:
Other, please indicate:
DATA PROTECTION ACT: If you do not wish your name to be divulged to a third party, please tick here:
Have you previously been a member of BSDHT?:
Yes
No
If yes, please indicate your membership number or when it was:
I wish to apply for full membership of BSDHT and agree to pay the annual subscription fee of £85.00:
Current Membership No (if renewing):
*
Indicates a field you must enter.
When you have completed the form, please click the Send Details button ONCE to send
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