COURSE FORMS 2014 - CDSHK RACDS Enrolment Form (GE… · The certified copies of following...

COURSE FORMS 2014

Updated: February 2014

GEN01 Enrolment Application ........................................................................................................................ 3

GEN02 Re-Enrolment Application ................................................................................................................... 6

GEN03 Method of Payment ............................................................................................................................ 9

GEN04 Admission to Membership ................................................................................................................ 10

GEN05 Admission to Fellowship ................................................................................................................... 13

MGDP01 Membership Program General Dental Practice (MRACDS(GDP)) Registration ............................. 16

MGDP02 MRACDS (GDP) Assessment Application ....................................................................................... 18

MGDP03 Viva Voce Examination – MRACDS(GDP) Registration for Examination ........................................ 19

FGDP20 Orientation Course (30 June - 11 July 2014) ................................................................................... 20

FGDP21 - 2013 Orientation Course Notes (USB Only) order form ................................................................ 21

FGDP22 Primary Examination All Centres except Hong Kong, Jordan & Malaysia ....................................... 22

FGDP23 Primary Examination - Hong Kong, Malaysia Only .......................................................................... 24

FGDP24 Exemption Application .................................................................................................................... 26

FGDP25 Final Exam Workshop Registration (14 & 15 June 2014) ................................................................ 28

FGDP26 Final Examination - Web Based Education Registration ................................................................. 29

FGDP27 - Final Fellowship Examination General Dental Practice 21 January 2015 ..................................... 30

MSDP01 Application for Eligibility - Membership in Specialist Dental Practice discipline ........................... 32

MSDP02 Application for Assessment of Eligibility to sit Membership Examination in a Specialist Dental

Practice .......................................................................................................................................................... 35

MSDP03 Application for Eligibility and Registration for a Conjoint Membership Examination in a Specialist

Dental Practice ............................................................................................................................................... 37

MSDP04 Registration for Membership Examination in a Specialist Dental Practice .................................... 39

MSDP05 Statement of verification of case reports ...................................................................................... 40

FSDP21 Assessment of Eligibility for Fellowship Examination in a Specialist Discipline............................... 41

FSDP22 Registration for Fellowship Examination – Specialist Dental Practice ............................................. 42

FOMS01 Exemption Application Form OMS – SST Examination................................................................... 43

FOMS02 Registration for Surgical Sciences and Training (SST) Examination ............................................... 45

FOMS03 - OMS Final Examination Registration ............................................................................................ 46

FOMS04 - OMS Accredited Trainee Registration Form ................................................................................. 47

FOMS05 – Accredited Trainee Registration Payment Form .......................................................................... 49

FOMS06 - Approved Trainee Registration Form ............................................................................................ 50

FOMS07 – Approved Trainee Registration Payment Form ............................................................................ 51

FOMS8 - Enrolled Candidate Status Form ..................................................................................................... 52

FOMS9 - Application for selection for Surgical Training Positions 2015 ....................................................... 53

FOMS10 - Oral and Maxillofacial Surgery Research Requirement ................................................................ 57

FOMS11 - Completion of Oral and Maxillofacial Surgery Training Program ................................................. 59

FOMS 12 - Application for Assessment of Eligibility For Final Examination .................................................. 60

ROYAL AUSTRALASIAN COLLEGE OF

DENTAL SURGEONS INCORPORATED

ABN 97 343 369 579

For Office Use Only

GEN01 Enrolment Application

1. PERSONAL DETAILS

Family Name (Block Letters)

Please attach your VERIFIED

passport-size photograph here

First Name (Block Letters)

Other Names (Block Letters)

Country of Birth

Date of Birth / / Sex Male Female

Day Month Year

Address for Correspondence

Telephone (W) (H) (Mob)

Fax Email

Photos are often taken at College events for use in College News and Bulletins.

If you do not wish to have your picture published for this purpose please tick here. No

2. CHOICE OF PRACTICE

GENERAL DENTAL PRACTICE SPECIALIST DENTAL PRACTICE

Membership (MRACDS program)

Primary Examination

Final Examination for Fellowship

Membership

OMS


(please specify)

Entry For Oral and Maxillofacial Surgery Training Program is via an eligibility application process only

3. ACADEMIC QUALIFICATIONS

Degrees Institutions Completed* Year of Graduation

* if not completed, please indicate the anticipated completion date.

4. PROFESSIONAL QUALIFICATIONS

Qualification Institution / Professional Body Years of Membership

or date obtained

5. CHECK LIST

Enrolment form

2 verified passport size photos

Enrolment fee (valid for a max 6yr period)

Certified copy of degree

Certified copy of current registration with Dental Board (practising certificate)which must have been issued within the previous 12 months

Proof of name change, if relevant

6. CERTIFICATION i. All certificate(s) must be accompanied by a certified translation when the certificate(s) is not in English

ii. To ensure the safety of documents certified photocopies rather than the originals should be provided. Ensure the signature is not photocopied, is original and states clearly the name and position of the signee as well as the date certified.

iii. Originals received will not be returned to the sender. The RACDS accepts documents certified by any of the following:

For Australian and NZ Residents:

A Fellow of the College

Justice of the Peace / Commissioner for Affidavits / Commissioner for Declarations

Administrative staff of the institution which originally issued the documents

Head of a Department of a Dental Hospital or Dental Facility

RACDS CEO

Judge of a Court / Master of a Court/ Magistrate

CEO of a Commonwealth Court

Registrar or Deputy Registrar of a Court / Clerk of a Court

Sheriff of the Court

Member of the Australian Defence Force – rank of Officer of higher

Police Officer – rank of Sergeant or higher

For Overseas Residents:


Justice of the Peace

Staff of an Australian Overseas Diplomatic

Mission

Administrative staff of the institution which

originally issued the documents

Registrar / Senior Staff of an overseas

Australian Education Institution (i.e. Australian Education International or authorised Australian education organization)

Officers verifying documents should write “This is a true copy of the original sighted by me” and sign the document, print their name, profession/occupation/organization, contact details and date verified. Justices of the Peace should also provide their registration number.

CANDIDATES, AND/OR THEIR IMMEDIATE FAMILY MEMBERS CANNOT CERTIFY THEIR OWN DOCUMENTS.

The certified copies of following documents to be attached to this form:

1. A statement/certificate from the Registering Authority in my country of residence that I possess a dental degree or qualification which currently entitles me to carry out the full practice of dentistry in that country, AND/OR

2. (for applicants for OMS Specialist Practice discipline) a statement/certificate from the Registering Authority in my country of residence that I possess a medical degree qualifying me to carry out the full practice of medicine

I HEREBY apply to be enrolled as a candidate of the College and enclose herewith the payment of the required fee.

SIGNATURE _______________________________ DATE __________________________ Unsigned applications will not be processed.

PLEASE NOTE: ENROLMENT FEE IS NON REFUNDABLE The completed application should be lodged either in person or by mail with:

Registrar Royal Australasian College of Dental Surgeons

Level 13, 37 York Street, Sydney NSW 2000 Australia Tel: +61 (0) 2 9262 6044 Fax: +61 (0) 2 9262 1974

Email: [email protected] Web: http://www.racds.org

7. PAYMENT Product # 114

CREDIT CARD PAYMENT

Visa MasterCard

Card Number

Expiry Date / CCV

Card Holder Name

Payment Amount

Overseas Resident AUD$595.00 (no GST)

Australian Resident AUD$654.50 (incl GST) A$

Signature:

Date:

PLEASE NOTE: Enrolment fee is Non-Refundable.

CHEQUE / MONEY ORDER / BANK DRAFT

Please note: (i) Please make payable to the “Royal Australasian College of Dental Surgeons” (ii) The College incurs substantial bank fees when an overseas bank has no clearing house in Australia. In order to avoid

these fee, you are asked to note the instruction below when arranging your bank draft in payment of your College account:-

Bank Drafts, in Australian Dollars and drafted to an Australian Bank Eg. ANZ Banking Corporation / Bank of China / Bank of Tokyo / Commonwealth Banking Corporation Hong Kong & Shanghai Banking Corporation / National Australia Banking Corporation Westpac Banking Corporation

(iii) Bank drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee.

CCV for Visa &

MasterCard is the final

three digits of the

number printed on the

signature strip on the

back of your card.

mailto:[email protected]

http://www.racds.org/



ABN 97 343 369 579

For Office Use Only

GEN02 Re-Enrolment Application

1. PERSONAL DETAILS

Family Name


passport-size photograph here

First Name

Other Names

Country of Birth

Date of Birth / /

Sex Male Female Day Month Year



Fax Email

Photos are often taken at College events for use in College News and Bulletins.

If you do not wish to have your picture published for this purpose please tick here. No

2. CHOICE OF PRACTICE

GENERAL DENTAL PRACTICE SPECIALIST DENTAL PRACTICE

Membership (MRACDS(GDP) program)

Primary Examination


Membership

OMS


(please specify)

Entry For Oral and Maxillofacial Surgery Training Program is via an eligibility application process only


Degrees Institutions Completed* Year of Graduation

* if not completed, please indicate the anticipated completion date.

Page 1 of 3

4. PROFESSIONAL QUALIFICATIONS

Qualification Institution / Professional Body Years of Membership

or date obtained

5. CHECK LIST

Enrolment form

2 verified passport size photos

Enrolment fee (valid for a max 6yr period)

Proof of name change, if relevant

Certified copy of current registration with Dental Board (practising certificate)which must have been issued within the previous 12 months or AHPRA print out for Australian residents

6. CERTIFICATION iv. All certificate(s) must be accompanied by a certified translation when the certificate(s) is not in English

v. To ensure the safety of documents certified photocopies rather than the originals should be provided. Ensure the signature is not photocopied, is original and states clearly the name and position of the signee as well as the date certified.

vi. Originals received will not be returned to the sender. The RACDS accepts documents certified by any of the following:






RACDS CEO





Member of the Australian Defence Force – rank of Warrant Officer or higher






Mission






CANDIDATES, AND/OR THEIR IMMEDIATE FAMILY MEMBERS CANNOT CERTIFY THEIR OWN DOCUMENTS.

Page 2 of 3

The certified copies of following documents to be attached to this form:

1. A statement/certificate from the Registering Authority in my country of residence that I possess a dental degree or qualification which currently entitles me to carry out the full practice of dentistry in that country, AND/OR

2. (for applicants for OMS Special Practice discipline) a statement/certificate from the Registering Authority in my country of residence that I possess a medical degree qualifying me to carry out the full practice of medicine

I HEREBY apply to be enrolled as a candidate of the College and enclose herewith the payment of the required fee.

SIGNATURE _______________________________ DATE______________________ Unsigned applications will not be processed.

PLEASE NOTE: ENROLMENT FEE IS NON REFUNDABLE The completed application should be lodged either in person or by mail with:

Registrar Royal Australasian College of Dental Surgeons

Level 13, 37 York Street, Sydney NSW 2000 Australia Tel: +61 (0) 2 9262 6044 Fax: +61 (0) 2 9262 1974

Email: [email protected] Web: http://www.racds.org


CREDIT CARD PAYMENT

Visa MasterCard

Card Number

Expiry Date / CCV

Card Holder Name

Payment Amount


Australian Resident AUD$654.50 (incl GST)

A$

Signature:

Date:

PLEASE NOTE: Enrolment fee is Non-Refundable.


Please note: (iv) Please make payable to the “Royal Australasian College of Dental Surgeons” (v) The College incurs substantial bank fees when an overseas bank has no clearing house in Australia. In order to avoid

these fee, you are asked to note the instruction below when arranging your bank draft in payment of your College account:-

Bank Drafts, in Australian Dollars and drafted to an Australian Bank Eg. ANZ Banking Corporation / Bank of China / Bank of Tokyo / Commonwealth Banking Corporation Hong Kong & Shanghai Banking Corporation / National Australia Banking Corporation Westpac Banking Corporation

(vi) Bank drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee.

Page 3 of 3 [

CCV for Visa &


three digits of the



back of your card.





ABN 97 343 369 579

For Office Use Only

GEN03 Method of Payment

Name


Telephone (T) (F) (Mob)

Payment For:

Credit Card Payment

Card Type Visa

MasterCard

Card Number

Expiry Date / CCV

Card Holder Name

Payment Amount

A$ Signature: Date:

Cheque / Money Order / Bank Draft

Please note:

(vii) Please make payable to the “Royal Australasian College of Dental Surgeons”

(viii) The College incurs substantial bank fees when an overseas bank has no clearing house in Australia. In order to avoid these fee, you are asked to note the instruction below when arranging your bank draft in payment of your College account:-

Bank Drafts, in Australian Dollars and drafted to an Australian Bank

Eg. ANZ Banking Corporation Bank of China Commonwealth Banking Corporation Hong Kong & Shanghai Banking Corporation National Australia Banking Corporation Westpac Banking Corporation

(ix) Bank drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee.

ELECTRONIC TRANSFER (AUSTRALIAN DOLLARS) Bank Westpac Banking Corporation (BSB) Account No (032-024) 80-1095 (swift code for overseas WPACAU2S) Branch 60 Martin Place, Sydney Australia. Account Name Royal Australasian College of Dental Surgeons Description (please enter description of payment made for ie. course/exam name)

Electronic Transfer: Please advise the College by telephone, email, fax or email of, the date and amount you Deposited the funds. (please note you are required to pay all bank fees incurred from this transactions)

Page 1 of 1

CCV for Visa &


three digits of the


signature strip n the

back of your card.

ROYAL AUSTRALASIAN COLLEGE

OF DENTAL SURGEONS

INCORPORATED

ABN 97 343 369 579

For Office Use Only

GEN04 Admission to Membership

1. Candidates for Admission – Please Note:

Candidates who have successfully fulfilled all the requirements for Membership shall make an application for admission to the Council of the College.

The Council may then admit successful candidates to Membership who then receive a Testamur of Membership and the privilege under By Law 3 to use the appropriate description.

Failure to remain a Member in good standing within the College removes the right and privilege of Membership including the use of the appropriate description.

2. Membership Type

MRACDS (General Dental Practice) Program MRACDS (Specialist Dental Practice) Program (please specify)

3. Personal Details

Family Name (Block Letters) Please attach your

passport-size

photograph here

(THIS PHOTO WILL BE INCLUDED IN THE NEXT YEAR BOOK)



Date of Birth / /



(for all College Mailings)

Principal Work Address

(if different from above)

Home Address (if different from above)


Fax Email

4. Practice Details

Please specify principal areas of work by placing a tick in appropriate box.

A. Academic Government employment Armed Services Private Practice

B. General Practice Medical Practice Specialist Practice (Please specify )

Page 1 of 3

5. Academic Qualifications

Degrees Institutions Years

6. Honours and Awards

Conferred Institution / Professional Body Years

7. Particulars of Academic Achievements (research, publications, scholarships, prizes)

8. Other Training and Experience

9. Particulars appearing on Certificate of Membership

State the exact form in which you desire to have your name appear on the Membership Testamur

(Please Print)

I hereby pledge myself as a condition of Membership of the College to practice dentistry and conduct my professional life in strict accordance with the Constitution and principles of the College. I pledge myself to obey all regulation, By-laws and Rules of the College now in force, which I hereby declare I have read, or any regulations, By-laws or Rules that may be adopted from time to time by the Council or by its governing body or duly delegated authority. I declare that I will submit to any penalties, including expulsion from the College that may be imposed by the Council or the governing body or duly appointed authority for violation of any regulation, By-law or Rule, or of this pledge.

I agree that all communications made by the Council or any of its officers and all answers to any questionnaire made by any Referee or Fellow of the College shall be absolutely privileged and shall for all purpose be deemed to be a privileged communication.

Declared at in the State of

(City) (state and/or country)

this day of of Signature:

(date) (month / year)

Before Me

(Name and Signature of Witness)

Page 2 of 3


Credit Card Payment

MasterCard Visa

Card Number Expiry Date

/ ccv Card Holder Name

Payment Amount



Signature:

Date:


Please make payable to the “Royal Australasian College of Dental Surgeons”

The College incurs substantial bank fees when an overseas bank has no clearing house in Australia. In order to avoid this fee, you are asked to note the instruction below when arranging your bank draft in payment of your College account:-


Eg. ANZ Banking Corporation / Bank of China / Bank of Tokyo / Commonwealth Banking Corporation, Hong Kong & Shanghai Banking Corporation / National Australia Banking Corporation Westpac Banking Corporation

Bank dr Drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee

Page 3 of 3

CCV for Visa & MasterCard

is the final three digits of the


signature strip on the back

of your card.


OF DENTAL SURGEONS

INCORPORATED

ABN 97 343 369 579

For Office Use Only

GEN05 Admission to Fellowship

1. CANDIDATES FOR ADMISSION – PLEASE NOTE: Candidates who have fulfilled the requirements for Fellowship including successful completion of Final Examination shall make an application for admission to the Council of the College.

The Council may then admit successful candidates to Fellowship who then receives a Certificate of Fellowship and the privilege under By Law 3 to use the appropriate description.

Failure to remain a Fellow in good standing within the College removes the right and privilege of Fellowship including the use of the appropriate description.

2. FELLOWSHIP TYPE

Fellowship (General Dental Practice) Program Fellowship (Specialist Dental Practice) Program (please specify)

3. PERSONAL DETAILS


passport-size

photograph here

(THIS PHOTO WILL BE

INCLUDED IN THE NEXT

YEAR BOOK)



Date of Birth / /



(for all College Mailings)

Principal Work Address

(if different from above)

Home Address (if different from above)


Fax Email

4. PRACTICE DETAILS

Please specify principal areas of work by placing a tick in appropriate box.

A. Academic Government employment Armed Services Private Practice

B. General Practice Medical Practice Specialist Practice (Please specify )

Page 1 of 3


Degrees Institutions Years

6. HONOURS AND AWARDS

Conferred Institution / Professional Body Years

7. PARTICULARS OF ACADEMIC ACHIEVEMENTS (RESEARCH, PUBLICATIONS, SCHOLARSHIPS, PRIZES)

8. OTHER TRAINING AND EXPERIENCE

9. PARTICULARS APPEARING ON CERTIFICATE OF FELLOWSHIP

State the exact form in which you desire to have your name appear on the Fellowship Testamur

(Please Print)

I hereby pledge myself as a condition of Fellowship of the College to practise dentistry and conduct my professional life in strict accordance with the Constitution and principles of the College. I pledge myself to obey all regulation, By-laws and Rules of the College now in force, which I hereby declare I have read, or any regulations, By-laws or Rules that may be adopted from time to time by the Council or by its governing body or duly delegated authority. I declare that I will submit to any penalties, including expulsion from the College that may be imposed by the Council or the governing body or duly appointed authority for violation of any regulation, By-law or Rule, or of this pledge.

I agree that all communications made by the Council or any of its officers and all answers to any questionnaire made by any Referee or Fellow of the College shall be absolutely privileged and shall for all purpose be deemed to be a privileged communication.

Declared at in the State of

(City) (state and/or country)

this day of of Signature:

(date) (month / year)

Before Me

(Name and Signature of Witness)

Page 2 of 3


CREDIT CARD PAYMENT

MasterCard

Visa

Card Number Expiry Date / ccv Card Holder Name

Payment Amount



Signature: Date:






Bank dr Drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee

Page 3 of 3

CCV for Visa & MasterCard is

the final three digits of the


signature strip on the back of

your card.



ABN 97 343 369 579

For Office Use Only

MGDP01 Membership Program General Dental Practice (MRACDS(GDP)) Registration

1. Personal Details






Fax Email

2. Acknowledgement

By signing this registration form, I acknowledge that all communication regarding the program will be sent to me via the email address I have provided. I also acknowledge that any information regarding my progress in the program can be forwarded to my Mentor as required.

Signature:

Unsigned applications will not be processed.

How did you hear about the MRACDS(GDP) program?

Australian Dental Association Publication

NZ Dental Association Publication

RACDS website

Communication from RACDS

Colleagues

Other (please specify)

Date:

Page 1 of 2



PAYABLE TO THE “ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS”

Must be made in Australian Dollars drawn on an Australian Bank.

Credit Card Payment (no GST)

Please debit my credit card

A$ Visa MasterCard

Card Number CCV

Expiry Date /

Card Holder Name

Signature:

Date:

Page 2 of 2

To be lodged by facsimile, email or mail to:

Registrar Royal Australasian College of Dental Surgeons Incorporated Level 13, 37 York St, Sydney NSW 2000 Australia Fax: +61 (0) 2 9262 1974 Email: [email protected] For further information please visit the college website or call the college office

Web: http://www.racds.org Tel: +61 (0) 2 9262 6044

CCV for Visa &


three digits of the number

printed on the signature

strip on the back of your

card.



ABN 97 343 369 579

For Office Use Only

MGDP02 MRACDS (GDP) Assessment Application To be lodged by facsimile, email or mail to: Royal Australasian College of Dental Surgeons Incorporated

Level 13, 37 York St, Sydney NSW 2000 Australia Tel: +61 (0) 2 9262 6044 Fax: +61 (0) 2 9262 1974 Email: [email protected] Web: http://www.racds.org

1. Personal Details



Contact details

Only complete if advising of new address


Fax Email

2. Application for Assessment

Short Answer Questions (specify modules)

Module Nominated Date of Assessment

Practice Management , Law, Ethics and Risk

Management

Medical Emergencies

Therapeutics in Dentistry , Pain and Pain

Management

Infection Control

Diagnosis and Treatment Planning

Examination Technique and Dental Imaging

Page 1 of 1




ABN 97 343 369 579

For Office Use Only

MGDP03 Viva Voce Examination – MRACDS(GDP) Registration for Examination

Date of Viva



Other Names (Block Letters) Date of Birth / / Day Month Year



Fax Email

Do you agree to have your correspondence/email address placed on a distribution list for College purposes? Yes No

I HEREBY apply to be registered for admission as a candidate for the Viva Voce of MRACDS

Candidates are reminded that registration is valid only for the examination to which the candidate has been admitted.

Signature:


Date:

PAYMENT Product # 144


– Payable to the “Royal Australasian College of Dental Surgeons”


CREDIT CARD PAYMENT (no GST)

Please debit my credit card A$ Visa MasterCard

Card Number Expiry Date / CCV Card Holder Name

Signature: Date:

Disclaimer:

The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are

cancelled or postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any

other costs incurred by the candidate.


is the final three digits of

the number printed on the


of your card.



ABN 97 343 369 579

For Office Use Only

FGDP20 Orientation Course (30 June - 11 July 2014)






Fax Email

If you do not wish to have your email address distributed to Orientation Course candidates please tick box

I wish to register for the following subjects: (Please tick)

All Anatomy Biochemistry Histology Microbiology Pathology Physiology

Note a) Your payment includes a USB containing lecture slides for the subjects registered.

b) For refunds of the registration fee refer to the Refunds Policy in Section 4 of the draft RACDS Handbook.

PLEASE NOTE: Candidates are not required to enrol in the College for this course; however enrolment is required for registration into the Primary Examination. Please be aware that the College will not refund your non enrolled course fee if you decide to enrol with the College after attending the Course.

Signature:


Date:

PAYMENT Product # 3 for Enrolled; or # 4 for Non-enrolled




CREDIT CARD PAYMENT


AUD$2800.00 (Enrolled Candidate/Fellow/Member )

AUD$3639.00 (Non Candidate/Non Fellow/Non Member) (Prices include GST)

Visa MasterCard

Card Number

Expiry Date / CCV Card Holder Name

Signature: Date:

Disclaimer: The College reserves the right to amend the timing and dates of Courses whenever conditions warrant. Where courses are cancelled or postponed, a full refund of the Course Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.

Page 1 of 1

* Please return to reach the RACDS Office by 1 June 2014 *

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FGDP21 - 2013 Orientation Course Notes (USB Only) order form

Name


Telephone (T) (F) (Mob)

($ 225.00 Overseas Residents OR $247.50 Australian Residents) Product # 105

Credit Card Payment

Card Type Visa MasterCard


/ Card Holder Name

Payment Amount

Signature: Date:


Please note:

(i) Please make payable to the “Royal Australasian College of Dental Surgeons”

(ii) The College incurs substantial bank fees when an overseas bank has no clearing house in Australia. In order to avoid these fee, you are asked to note the instruction below when arranging your bank draft in payment of your College account:-


Eg. ANZ Banking Corporation Bank of China Bank of Tokyo Commonwealth Banking Corporation Hong Kong & Shanghai Banking Corporation National Australia Banking Corporation Westpac Banking Corporation

(iii) Bank drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee.

PAGE 1 OF 1

LEVEL 13, 37 YORK STREET, SYDNEY NSW 2000, AUSTRALIA TEL: +61 2 9262 6044 FAX: +61 2 9262 1974

EMAIL: [email protected] WEB: www.racds.org

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FGDP22 Primary Examination All Centres except Hong Kong, Jordan & Malaysia

24 November – 3 December 2014


Please enclose your VERIFIED

passport-size photograph here if not

already provided in the past

six months



Country of Birth

Date of Birth / /




Fax Email

If you do not wish to have your email address placed on a distribution list for College purposes please tick box

Dental Qualification

Degree University Year

For applicants for OMS Specialist Practice discipline ONLY:

Medical Qualification


I HEREBY apply to take the written papers in the following venue: (tick whichever is applicable)

□ Adelaide □ Auckland □ Brisbane □ Melbourne □ Perth □ Singapore □ Sydney

Degree

I HEREBY apply to be registered for all six subjects as a Candidate for the Primary Examination to be held in November/December 2014 and enclose A$2221.00 payment of the required fee, OR

I HEREBY apply to be registered for one or two subjects as a Candidate for the Primary Examination to be held in November/December 2014 and enclose either A$516 or A$1032 in payment of the required fee.

PLEASE NOTE: CANDIDATES MUST REGISTER FOR ALL 6 SUBJECTS ON THE FIRST ATTEMPT OF THIS EXAMINATION. CANDIDATES CAN ONLY ELECT TO SIT 1 OR 2 SUBJECTS IF REPEATING SUBJECTS FAILED PREVIOUSLY.

PAGE 1 OF 2

Note:-

(a) For refunds of the registration fee refer to the Refunds Policy in Section 4 of the draft RACDS Handbook.

(b) Registration for the Primary Examination must be made on or before 1 September and the examination will be taken in the month of November/December immediately following.

(c) If an Australian venue fails to reach a minimum of 5 candidate registrations this venues will be withdrawn for 2013.

(d) If Auckland and Singapore venues fails to reach a minimum of 10 candidate registrations these venues will be withdrawn for 2013.

Signature:


Date:

Change of examination dates: Disclaimer: The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.

PAYMENT Product # 6 or # 7 or # 13

CREDIT CARD PAYMENT

MasterCard Visa


/ ccv

Card Holder Name

Amount AUD$ (no GST)

Signature: Date:






Bank Drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee

PAGE 2 OF 2


is the final three digits of

the number printed on the


of your card.



ABN 97 343 369 579

For Office Use Only

FGDP23 Primary Examination - Hong Kong, Malaysia Only

WRITTEN PAPERS: 24 - 26 November and VIVA VOCE: 6 – 8 Dec 2014





six months



Country of Birth

Date of Birth / /




Fax Email

If you do not wish to have your email address placed on a distribution list for College purposes please tick box



For applicants for OMS Specialist Practice discipline ONLY:

Medical Qualification


I HEREBY apply to be registered for all six subjects as a Candidate for the Primary Examination to be held in:

Hong Kong in December 2014 and enclose A$2,221 payment of the required fee for the Written examination and A$3,296 payment of the required fee for the Viva Voce examination. (I understand that the fee of A$3,296 is not refundable.) Total Sum enclosed: A$5,517

Malaysia - in December 2014 and enclose A$2,221payment of the required fee for the Written examination and A$3,296 payment of the required fee for the Viva Voce examination. (I understand that the fee of A$3,296 is not refundable.) Total Sum enclosed: A$5,517

I HEREBY apply to be registered for one or two subjects as a Candidate for the Primary Examination to be held in

□ Hong Kong in December 2014 and enclose either A$516 or A$1,032 payment of the required fee for the Written examination and A$585

payment of the required fee for the Viva Voce examination. (I understand that the fee of A$585 is not refundable.) Total Sum enclosed: A$1,069 or A$1,570

□ Malaysia - in December 2014 and enclose either A$516 or A$1032 payment of the required fee for the Written examination and A$585 in

payment of the required fee for the Viva Voce examination. (I understand that the fee of A$585 is not refundable.) Total Sum enclosed: A$1,101 or A$1,617

Note:-

(e) For refunds of the registration fee refer to the Refunds Policy in Section 4 of the draft RACDS Handbook.

(f) Registration for the Primary Examination must be made on or before 1 August and the examination will be taken in the month of December immediately following.

(g) If Hong Kong & Malaysian venues fails to reach a minimum of 14 and 12 candidate registrations respectively, these venues will be withdrawn in 2014.

Page 1 of 2

Signature:


Date:


PAYMENT

CREDIT CARD PAYMENT

MasterCard Visa


/ ccv

Card Holder Name

Amount AUD$

Signature: Date:





Eg. ANZ Banking Corporation / Bank of China / Bank of Tokyo / Commonwealth Banking Corporation, Hong Kong & Shanghai Banking Corporation / National Australia Banking Corporation / Westpac Banking Corporation

Bank Drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee

PAGE 2 OF 2





your card.



ABN 97 343 369 579

For Office Use Only

FGDP24 Exemption Application

1. PERSONAL DETAILS






Fax Email

Please note: An EMAIL address MUST be supplied by applicants for correspondence.

2. QUALIFICATIONS

Passed the Primary Examination for Fellowship in : -

The Faculty of Dental Surgery in the Royal College of Surgeons of England, or

The Faculty of Dental Surgery in the Royal College of Surgeons of Edinburgh, or

The Faculty of Dental Surgery in the Royal College of Physicians and Surgeons of Glasgow, or

The Faculty of Dentistry of the Royal College of Surgeons in Ireland

Passed the Primary Examination for Fellowship or MFGDP Part 1, MJDF or Part A of the

MFDS Examination in: -

The Royal College of Surgeons of England, or The Royal College of Surgeons of Edinburgh, or The Royal College of Physicians and Surgeons of Glasgow, or The Royal College of Surgeons in Ireland

Holders of Membership from the above Colleges

Passed Part I Examination for Fellowship in the Royal Australasian College of Surgeons

Holders of senior University degrees (eg. Masters or PhD) in the health sciences. Such degrees shall have been of not less than Two Years Full Time study. (Please refer to Section 3 Check List note (iii))

3. CHECK LIST

Exemption Application Form

Certified copy of the Qualification

Enrolment Application Form If Not Already Enrolled.

If unsuccessful, 60% of the fee paid for the application will be refunded.

Page 1 of 2

Please note:

(i) Applicants are required to enrol with the College before the exemption can be processed.

(ii) Applicants will be required to submit the exemption applications BEFORE 1 OCTOBER in order to register to the Final Examination in the month of January in the following year.

(iii) Applicants who have successfully completed a Masters Degree need to provide evidence that the degree was a Two Year Full Time course. This evidence can be one of the following:

A letter from the University, stating you successfully completed the Masters degree and that it was a Two Year Full Time course, or

Information about the Masters Course from the University handbook stating the length of the course (Two Years) and mode of study (Full Time).

4. CERTIFICATION vii. All certificate(s) must be accompanied by a certified translation when the certificate(s) is not in

English viii. To ensure the safety of documents certified photocopies rather than the originals should be

provided. The RACDS accepts documents certified by any of the following:



Staff of an Australian Overseas

Diplomatic Mission


Head of Department of a Dental Hospital or Dental Faculty

Officers verifying documents should write “This is a true copy of the original sighted by me” and sign the document, print their name, profession/occupation/organization, contact details and date verified. Justice of the Peace should also provide their registration number.

CANDIDATES CANNOT CERTIFY THEIR OWN DOCUMENTS.

I HEREBY apply for an exemption from the Primary Examination.

Signature:


Date:



–Payable to the “Royal Australasian College of Dental Surgeons”


CREDIT CARD PAYMENT


AUD$ 1,039.00 (no GST) Visa MasterCard

Card Number Expiry Date / ccv

Card Holder Name

Signature: Date:

PAGE 2 OF 2

CCV for Visa &


three digits of the number

printed on the signature

strip on the back of your

card.



ABN 97 343 369 579

For Office Use Only

FGDP25 Final Exam Workshop Registration (14 & 15 June 2014)

* Please return to reach the RACDS Office by 1 May 2014*

Family Name

First Name

Other Names



Fax Email Do you agree to have your email address to be distributed to candidates attending the Final Exam Workshop? Yes No


I intend to present for the Final Examination in 2015 and in Part II of the Examination I will be electing Section: (Please tick one)

Oral Medicine, Oral Surgery and Oral Pathology

Restorative Dentistry and Periodontics

Paediatric Dentistry and Orthodontics

This information will assist us in the organisation of case presentation sessions.

Note (a) For refunds of the registration fee refer to the Refunds Policy in Section 4 of the draft RACDS Handbook.

Signature: Unsigned applications will not be processed.

Date:



– Payable to the “Royal Australasian College of Dental Surgeons” Must be made in Australian Dollars drawn on an Australian Bank.

CREDIT CARD PAYMENT

Please debit my credit card AUD$1,348.00 (incl GST) Visa MasterCard

Card Number

Expiry Date

/ CCV Card Holder Name Signature:

Date:

Disclaimer:

The College reserves the right to amend the timing and dates of Courses whenever conditions warrant. Where courses are cancelled or postponed, a full refund of the Course Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.

Page 1 of 1

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FGDP26 Final Examination - Web Based Education Registration






Fax EMAIL

I wish to register for the 2014 RACDS Final Examination Web Based Education Program and enclose the registration fee of A$541.00 (incl. GST)

I understand that the registration fee covers two separate segments (images to be viewed via the College website in August and October). It is my responsibility to access the program after registration, view the images and accompanying questions during the specified periods and email my responses to the College by the due dates. No refund, partial or full, will be given if a candidate fails to participate in one or more segments.

Signature:


Date:





CREDIT CARD PAYMENT (incl GST)


Card Number Expiry Date / CCV

Card Holder Name

Signature: Date:

Page 1 of 1

CCV for Visa &

MasterCard is the

final three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FGDP27 - Final Fellowship Examination General Dental Practice 21 January 2015





six months



Date of Birth _____ / _____ / _____

day month year Sex Male Female

Sex Male Female



Fax Email




I HEREBY apply to take the written papers in the following venue: (tick whichever is applicable)

Auckland Hong Kong Melbourne Sydney

In the Final Examination I elect to take:

(Please tick General Dentistry & one Elective; if re-presenting, tick only the relevant section)

General Dentistry Restorative Dentistry and Periodontics

Oral Medicine, Oral Surgery and Oral Pathology Paediatric Dentistry and Orthodontics

I HEREBY apply to be registered for admission as a Candidate for the Final Examination to be held in January 2014.

Year Primary Passed Or Year Exemption Granted

I HEREBY apply to be registered for re-admission as a Candidate for the Final Examination to be held in January 2014. (Part I or Part II only)

Year Final Exam Previously Sat

I HEREBY DECLARE that at the time of the Final Examination I have qualified to practice dentistry for three years or more and that during that time I have spent two years in the general practice of dentistry (including Armed Services, hospital and institut ional appointments) as required by Regulations 18 and 19. (Registration for admission to the Final Examination closes on 31 October each year and the examination will be taken in the month of January immediately following.)

Signature:


Date:

Page 1 of 2

Note:-

(h) For refunds of the registration fee refer to Refunds Policy in Section 4 of the draft RACDS Handbook.

(i) Registration for the Final Examination must be made on or before 1 November and the examination will be taken in the month of January immediately following.

(j) If an Australian venue fails to reach a minimum of 5 candidate registrations this venues will be withdrawn for 2014.

(k) If Auckland and Hong Kong venues fails to reach a minimum of 10 candidate registrations these venues will be withdrawn for 2014.

(l) If the Malaysian venues fails to reach a minimum of 12 candidate registrations these venues will be withdrawn for 2014.

Signature:


Date:








AUD$ Visa MasterCard

Card Number

Expiry Date / CCV

Card Holder Name

Signature: Date:

Page 2 of 2

CCV for Visa &


three digits of the



back of your card.

Eligibility for Membership in the Specialist Dental Practice discipline of: (Please tick one)

Dental Public Health Paediatric Dentistry

Endodontics Periodontics

Oral Medicine Prosthodontics

Orthodontics Special Needs Dentistry

TO BE COMPLETED BY APPLICANT. Applicants must show under which clause they meet eligibility for Membership. For more information please refer to Clause 3.4.3 of the Appendix to the Regulations (under Governance on the RACDS website).

I _____________________________________________ HEREBY declare that I meet the requirements for Membership as set out in

(Full Name – Block Letters) Appendix to the Regulations under

Signature: _______________________________________________________ Date: ________________________ Unsigned applications will not be processed

University / Institution

Program

Duration Full Time/Part Time

Date of commencement/

MSDP01 Application for Eligibility - Membership in Specialist Dental Practice discipline

For applicants who have completed a specialist program prior to 30/6/09 or for Dental Public Health program prior to 31/12/2010

Family Name

(Block Letters)

First Name

(Block Letters)

Other Names

(Block Letters)

Date of Birth _____ / _____ / _____ Day Month Year


Telephone (work)

(home)

(mobile)

(fax)

Email





ABN 97 343 369 579

For Office Use Only

Completion

Page 1 of 2

CERTIFICATION

ix. All certificate(s) must be accompanied by a certified translation when the certificate(s) is not in English x. To ensure the safety of documents certified photocopies rather than the originals should be provided. Ensure

the signature is not photocopied, is original and states clearly the name and position of the signee as well as the date certified.

xi. Originals received will not be returned to the sender. The RACDS accepts documents certified by any of the following:






RACDS CEO





Member of the Australian Defence Force – rank of Officer of higher






Mission






CANDIDATES, AND/OR IMMEDIATE FAMILY MEMBERS CANNOT CERTIFY THEIR OWN DOCUMENTS.



– PAYABLE TO THE “ROYAL AUSTRALASIAN COLLEGE OF DENTAL SURGEONS”




Card Number


Signature:

Date:

Page 2 of 2

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

MSDP02 Application for Assessment of Eligibility to sit Membership Examination in a Specialist Dental Practice



passport-size photograph here if not already provided in the

past six months


Other Names

Date of Birth



Fax Email


I HEREBY apply to be registered for admission as a candidate for the Membership Examination in the Specialist Dental Practice

discipline of: (Please tick one)

Dental Public Health

Endodontics

Oral Medicine

Orthodontics

Paediatric Dentistry

Periodontics

Prosthodontics

Special Needs Dentistry

TO BE COMPLETED BY APPLICANT

University / Institution:

Program: Duration: Completed Yes

Full Time / Part Time Completed No go to section below

TO BE COMPLETED BY PROGRAM DIRECTOR / HEAD OF TRAINING

I _______________________________________ HEREBY confirm _________________________________ is enrolled in the above

program and (Full Name – Block Letters)

I anticipate clinical training will be completed by :______________________(date). Signature: _______________________________________________________ Date: ________________________

Note:

(a) Candidates will be deemed eligible if clinical training is completed within six months of Membership Examination

(b) For refunds of the registration fee refer to Refunds Policy in Section 4 of the draft RACDS Handbook

I _________________________________________________ hereby apply for Assessment of Eligibility to sit Membership Examination in the Specialist Practice discipline above.

Change of examination dates:

Disclaimer:

The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.

PAYMENT CHEQUE / MONEY ORDER / BANK DRAFT





Card Number


Signature: Date:

Closing Date for Receipt of this form: 1 March

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

MSDP03 Application for Eligibility and Registration for a Conjoint Membership Examination in a Specialist Dental Practice



passport-size photograph here if not already provided in the

past six months


Other Names Date of Birth



Fax Email


I HEREBY apply to be registered for admission as a candidate for the Membership Examination in the Specialist Dental Practice discipline of: (Please tick one)


Endodontics

Oral Medicine Orthodontics

Conjoint- MOrth/MRACDS(ORTH)

Venue __________________

Conjoint- MoU with a University

University _________________

Paediatric Dentistry Periodontics Prosthodontics Special Needs Dentistry

TO BE COMPLETED BY APPLICANT For attachments required, refer to Clause 3 of the Appendix to the Regulations

University / Institution

Approved Program Duration Completed Yes

Full Time / Part Time Completed No go to section below

TO BE COMPLETED BY PROGRAM DIRECTOR/HEAD OF TRAINING

I _______________________________________ hereby confirm _________________________________ is enrolled in the above program and (Full Name – Block Letters)

I anticipate clinical training will be completed by:______________________(date).

Signature: _______________________________________________________ Date: ________________________

Note:-

(m) Candidates will only be deemed eligible if clinical training is completed within six months of Membership Examination

(n) For refunds of the registration fee refer to Refunds Policy in Section 4 of the draft RACDS Handbook.

I ___________________________________________ I hereby apply for Assessment of Eligibility to sit Membership Examination

(Full Name – Block Letters) in the Specialist Practice discipline specified above.

Signature: _______________________________________________________ Date: ________________________ Unsigned applications will not be processed Change of examination dates. Disclaimer: The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.






Card Number


Signature: Date:

Closing Date for Receipt of this form: 16 March for MoU(Edin) June Examination. All others - 1 August

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

MSDP04 Registration for Membership Examination in a Specialist Dental Practice


VERIFIED

passport-size photograph here if not already

provided in the past six months





Fax Email


I HEREBY apply to be registered for admission as a candidate for the Membership Examination in the Special Practice discipline of:

(Please tick one)


Endodontics

Oral Medicine

Orthodontics


Periodontics Prosthodontics


i. Candidates are reminded that registration is valid only for the examination to which the candidate has been admitted.

ii. Candidates are referred to Regulations 9 and 10 of the Regulations for Examination and Fellowship regarding reimbursement of registration fees.

Signature:


Date:





Please debit my credit card A$

Visa MasterCard


Signature: Date:

Disclaimer:

The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.

Closing Date for Receipt of this form: 1 May





your card.



ABN 97 343 369 579

Level 13, 37 York Street, Sydney NSW 2000 Australia Telephone: +61(0)2 9262 6044 Facsimile: +61(0)2 9262 1974

E-mail: [email protected] Web: http://www.racds.org

MSDP05 Statement of verification of case reports

Examination for Membership / Fellowship in a Specialty Dental Practice

I certify that the case reports submitted are of my own work. I further certify that I have personally been involved in patient management and that my role has been indicated where clarification is necessary, such as in the case of multidisciplinary management. Signed: __________________________________________ Candidate name: ____________________________________ Date: ________________________________




ABN 97 343 369 579

For Office Use Only

FSDP21 Assessment of Eligibility for Fellowship Examination in a Specialist Discipline



Other Names (Block Letters) Date of Birth / /

Day Month Year



Fax Email

Postgraduate Qualification

Degree University Year MRACDS Year awarded

I HEREBY apply for assessment of eligibility for examination in: (Please tick one)


Endodontics

Orthodontics


Prosthodontics


Oral Medicine Periodontics

and enclose A$ in payment of the required fee.

I intend / do not intend to register for examination under clause 31 of the Regulations for Examination in Special Fields.

Signature:


Date:

ATTACHMENTS REQUIRED

1.Curriculum vitae , which includes evidence of length of practice in the discipline, exclusive practice in specialist discipline, Continuing Professional Development, Research and Publications, Professional and Community Service,

2. Log book summary

3. Names and addresses of at least two Members or Fellows of the College practising in the Specialist Dental Practice discipline or letter of good standing from a Registering Authority.

NOTE: All Attachments will need to be presented in PDF format and 1 certified hard copy. Candidates will be advised if their application is successful, following which a separate form and fee is required for registration for the Final Examination. Refer to the College Calendar of Events for specific closing dates for exam registration.

PAYMENT Cheque / Money Order / Bank Draft



Must be made in Australian Dollars drawn on an Australian Bank



Signature: Date:

Disclaimer: The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or

postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the

candidate

Closing Date for Receipt of this form: 1 March

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FSDP22 Registration for Fellowship Examination – Specialist Dental Practice


Please attach your VERIFIED passport-size photograph here if not already provided in the

past six months





Fax Email


I HEREBY apply to be registered for admission as a candidate for the Final Examination in the Specialist Practice discipline of:

(Please tick one)

Dental Public Health Periodontics

Endodontic Paediatric Dentistry

Oral Medicine Prosthodontics

Oral and Maxillofacial Surgery Special Needs Dentistry

Orthodontics

Note:-

i. Candidates are reminded that registration is valid only for the examination to which the candidate has been admitted. ii. For refunds of the registration fee refer to Refunds Policy in Section 4 of the draft RACDS Handbook.

iii. Candidates must submit three copies of case reports on CDROM and one hard copy one month prior to the examination

date (except OMS).

Signature:


Date:

PAYMENT







Signature: Date:

Disclaimer: The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.

Closing Date for Receipt of this form: 1 May

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FOMS01 Exemption Application Form OMS – SST Examination

1. PERSONAL DETAILS






Fax Email

Please note: An EMAIL address MUST be supplied by applicants for correspondence.

2. QUALIFICATION/S FOR EXEMPTION

Passed the following examination for Fellowship in The Royal Australasian College of Surgeons:

BST - RACS

Generic SET - RACS

OTHER (PLEASE SPECIFY) ______________________________________________________________

3. CHECK LIST

Exemption Application Form

Certified copy of the qualification/s

Exemption fee (Payable on application. If unsuccessful, 60% of the fee will be refunded)

Please note:

(i) Applicants will be required to submit the exemption application BEFORE 15 FEBRUARY in order to receive exemption from the SST Examination in the same year.

4. CERTIFICATION

I. All certificate(s) must be accompanied by a certified translation when the certificate(s) is not in English II. To ensure the safety of documents, certified photocopies rather than the originals should be provided.

The RACDS accepts documents certified by any of the following:



Staff of an Australian Overseas

Diplomatic Mission


Head of Department of a Dental Hospital or Dental Faculty

Officers verifying documents should write “This is a true copy of the original sighted by me” and sign the document, print their name, profession/occupation/organization, contact details and date verified. Justice of the Peace should also provide their registration number.

CANDIDATES CANNOT CERTIFY THEIR OWN DOCUMENTS.

I HEREBY apply for an exemption from the OMS SST Examination.

Signature:


Date:








Signature: Date:

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FOMS02 Registration for Surgical Sciences and Training (SST) Examination


CERTIFIED passport-size

photograph here if not already provided in the

past six months


Other Names Date of Birth:



Fax Email

OMS - Clinical Year Undertaken:

Location/s: _________________________________ Date/s: ___________ to ____________

Surgery in General Year/s Undertaken:

Location/s: ___________________________________ Date/s: ____________ to ____________

I certify that the above information is correct and I support the trainee’s readiness to undertake the SST examination.

Signature (Supervisor of Training) : _______________________________________ Position held: ____________________________

Please print name: ______________________________________________

CANDIDATES ARE REMINDED THAT REGISTRATION IS VALID ONLY FOR THE EXAMINATION TO

WHICH THE CANDIDATE HAS BEEN ADMITTED. For refunds of the registration fee refer to Refund Policy

Applicants Signature:


Date:



Payable to the “Royal Australasian College of Dental Surgeons”




Card Number

Expiry Date / ccv Card Holder Name

Signature: Date:

Disclaimer: The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or

postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the

candidate.

CLOSING DATE FOR RECEIPT OF THIS FORM: 1 March

CCV for Visa & MasterCard is

the final three digits of the



your card.



ABN 97 343 369 579

For Office Use Only

FOMS03 - OMS Final Examination Registration



passport-size photograph here if not already

provided in the past six months


Other Names

Date of Birth



Fax Email


I HEREBY apply to be registered for admission as a candidate for the Final Examination in the Specialty Practice of Oral and Maxillofacial Surgery.

i. Candidates are reminded that registration is valid only for the examination to which the candidate has been admitted. ii. For refunds of the registration fee refer to Refunds Policy in Section 4 of the draft RACDS Handbook.

Signature:


Date:







Card Number

Expiry Date / ccv Card Holder Name

Signature: Date:

Disclaimer: The College reserves the right to amend the timing and dates of examinations whenever conditions warrant. Where examinations are cancelled or postponed, a full refund of the Examination Registration fee will be issued. The College takes no responsibility for any other costs incurred by the candidate.

Closing Date for Receipt of this form: 1 July

CCVV for Visa &


three digits of the



back of your card.


OF DENTAL SURGEONS

INCORPORATED

ABN 97 343 369 579

For Office Use Only

FOMS04 - OMS Accredited Trainee Registration Form

1 PERSONAL DETAILS

Family Name

First Name

Other Names



Fax Email

2 TRAINING (TICK UPCOMING YEAR OF TRAINING, FILL OUT FOR ALL COMPLETED)

Year commenced OMS training program

(BST(OMS) or OMS 1)

Pre-2004 2004 - 2009 2010 and beyond

OMS1 – Start date:

Expected end date:

1st or only Position Occupied:

2nd Position Occupied (if applicable):


Expected end date:




Expected end date:




Expected end date:



RACS courses

(to be completed before OMS 3)

ASSET EMST CCrlSP

3 TRAINING INSTITUTION FOR 2014

Hospital Name

Address 1

Address 2

Address 3

Start Date:

4 SUPERVISION FOR 2014

Supervisor’s Name

Contact details Phone: Email:

Address 1

Address 2

Address 3

Supervisor’s signature Date

Please print name

5 Statement verifying trainee status to be completed by the Director of Training

I confirm that the above person is currently a trainee in Oral and Maxillofacial Surgery at the Royal Australasian College of Dental Surgeons and that the above post details (if applicable) are correct.

DoT signature Date

Please print name

Trainee Commencement Date:

6 TRAINEE DECLARATION

As a registered trainee with the Oral and Maxillofacial Surgery (OMS) training program of the Royal Australasian College of Dental Surgeons Incorporated (RACDS), I agree to abide by the terms and conditions of the training program as stated in the Handbook.

I understand that financial membership of the RACDS must be maintained for the duration of training.

I acknowledge that my information will be handled in accordance with the RACDS Privacy Policy and I agree that program information may be used for the purposes of evaluation and research.

Trainee signature Date

Please print name

7 SUBMISSION CHECKLIST

The payment for the trainee registration fee is enclosed.

I have signed the form.

The form has been signed by my Director of Training.

All required sections are filled out, including section 2.

Please note, the College also must receive the following documents (if not already submitted).

Six Monthly Assessment Jan-Jun & Jul-Dec for the previous year (signed by Supervisor of Training and

Director of Training).

Annual Logbook Summary 2013 (signed by your Director of Training).



ABN 97 343 369 579

For Office Use Only

FOMS05 – Accredited Trainee Registration Payment Form

Name

Payment For Trainee occupying an accredited post Australian Resident

$4264.70 (incl GST) Overseas Resident

$3877.00 (ex GST)

CREDIT CARD PAYMENT


Card Number

Expiry Date / CCV

Card Holder Name

Payment Amount

A$ Signature Date

CHEQUE/ MONEY/ ORDER/ BANK DRAFT

Please note:

(x) Please make payable to the ‘Royal Australasian College of Dental Surgeons’, Level 13, 37 York Street, Sydney NSW 2000, Australia

(xi) The College incurs substantial bank fees when an overseas bank has no clearing house in Australia. In order to avoid these fee, you are asked to note the instruction below when arranging your bank draft in payment of your College account:-



(xii) Bank drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee.

ELECTRONIC TRANSFER (AUSTRALIAN DOLLARS) Bank Westpac Banking Corporation (BSB) Account No (032-024) 80-1095 (swift code for overseas WPACAU2S) Branch 60 Martin Place, Sydney Australia. Account Name Royal Australasian College of Dental Surgeons Description (Please enter your surname and ID Number. Contact the College if you are not

aware of your ID number) Electronic Transfer: Please advise the College by telephone, email, fax or email of the date and amount you

deposited. Please note you are required to pay all bank fees incurred from this transaction.

THIS BECOMES A TAX INVOICE UPON PAYMENT

CCV for Visa &


three digits of the



back of your card.



ABN 97 343 369 579

For Office Use Only

FOMS06 - Approved Trainee Registration Form 1 PERSONAL DETAILS

Family Name

First Name

Other Names



Fax Email

2 TRAINING

Year Accredited Training Completed: ___________________

The Training year 2014 Program has been approved by the Board of Studies

3 Statement verifying trainee status to be completed by the Director of Training

I confirm that I have agreed to act as Director of Training for ________________________________(name of Trainee) during 2014 and that the above post details (if applicable) are correct.

DoT signature Date

Please print name

4 TRAINEE DECLARATION

As a registered trainee with the Oral and Maxillofacial Surgery (OMS) training program of the Royal Australasian College of Dental Surgeons Incorporated (RACDS), I agree to abide by the terms and conditions of the training program as stated in the Handbook.

I understand that financial membership of the RACDS must be maintained for the duration of training.

I acknowledge that my information will be handled in accordance with the RACDS Privacy Policy and I agree that program information may be used for the purposes of evaluation and research.

Trainee signature Date

Please print name


The payment for the trainee registration fee is enclosed.

I have signed the form.

The form has been signed by my Director of Training.

All required sections are filled out, including section 2.

The Director of Training for this year is _______________________________________.



ABN 97 343 369 579

For Office Use Only

FOMS07 – Approved Trainee Registration Payment Form

Name

Payment For Trainee occupying an approved post Australian Resident

$193.60 (incl. GST) Overseas Resident

$176.00 (ex GST)

CREDIT CARD PAYMENT



/ CCV Card Holder Name

Payment Amount

A$ Signature

Date

CHEQUE/ MONEY/ ORDER/ BANK DRAFT

Please note:

(xiii) Please make payable to the ‘Royal Australasian College of Dental Surgeons’, Level 13, 37 York Street, Sydney NSW 2000 Australia

(xiv) The College incurs substantial bank fees when an overseas bank has no clearing house in Australia. In order to avoid these fee, you are asked to note the instruction below when arranging your bank draft in payment of your College account:-



(xv) Bank drafts drawn on a bank, other than those listed above or in a non-Australian currency may incur a bank processing fee.

ELECTRONIC TRANSFER (AUSTRALIAN DOLLARS) Bank Westpac Banking Corporation (BSB) Account No (032-024) 80-1095 (swift code for overseas WPACAU2S) Branch 60 Martin Place, Sydney Australia. Account Name Royal Australasian College of Dental Surgeons Description (Please enter your surname and ID Number. Contact the College if you are not aware of

your ID number)

Electronic Transfer: Please advise the College by telephone, email, fax or email of the date and amount you deposit. Please note you are required to pay all bank fees incurred from this transaction.

THIS BECOMES A TAX INVOICE UPON PAYMENT

CCV for Visa &


three digits of the



back of your card.


OF DENTAL SURGEONS

INCORPORATED

ABN 97 343 369 579

For Office Use Only

Oral and Maxillofacial Surgery

FOMS8 - Enrolled Candidate Status Form

1 PERSONAL DETAILS

Family Name

First Name

Other Names



Fax Email

2 CURRENT STATUS

Year Completed BST OMS:

Completing a Medical or Dental Degree Approved leave From To

Completing a Surgery in General year

Completing an intern year

Completing an off-service rotation to a medical or surgical unit or to complete a PhD.

Completing an overseas posting for which I have received prospective approval from the Board of Studies for Oral and Maxillofacial Surgery.


All required sections are filled out.



ABN 97 343 369 579

For Office Use Only

Oral and Maxillofacial Surgery

FOMS9 - Application for selection for Surgical Training Positions 2015

Replies to the following questions MUST BE PRINTED CLEARLY IN BLACK

Applications close on 16 May 2014 [email protected]

A. Personal Details

Family Name

Please enclose your certified passport size

photograph here

First Name

Other Names

Date of Birth ______ / _______ / _______ Sex Male Female



Email Address

(Please circle)

1 Are you a citizen of Australia or New Zealand?

Yes (Go to Q2)

No

If NO, are you a permanent resident of Australia or New Zealand?

Yes No

i. If you are a permanent resident of Australia, have you passed the Australian Dental Council examinations?

Yes No

If NO, do you have full dental registration in New Zealand?

Yes No

ii. If you are a permanent resident of Australia, have you passed both components of the Australian Medical Council Examinations?

Yes No

If NO, do you have full medical registration in New Zealand?

Yes No

2 Please provide your Dental and Medical Registration Number and State/Region of Registration (attach documents from Dental and Medical Board):

Dental Registration Number State/Region of Registration

Medical Registration Number State/Region of Registration


B. Qualifications

1 List ALL of the Qualifications/Fellowships/Memberships/Primary Examination successfully completed

Degree/Fellowships Institution Year Completed

2 Curriculum Vitae – Please attached a detailed curriculum vitae that includes the following:

- Your undergraduate academic results

- Any awards, scholarships or notable achievements you have received during your Dental and Medical Courses under the relevant headings etc. Provide details including institution, year, type of award and documentary evidence (if available).

- Details of all positions

- Published articles

- Papers / posters presented

- List formal courses/meetings attended e.g. plating, RACDS convocation, implant, risk management, ANZAOMS conference

- Significant achievements outside of medicine / dentistry

3 Are you an OMS enrolled candidate of the Royal Australasian College of Dental Surgeons?

Yes No

If NO, proceed to question number 5

If YES, proceed to question number 4

4 Have you completed the RACDS Basic Surgical Training Program Yes No

When did you complete your BST (OMS) Year ________

Have you completed a BST (OMS) year and presently doing your SIG year? Yes No

5 List ALL PREVIOUS hospital appointments for medicine and dentistry (Please attach separate sheet)

Year Hospital Rotation Consultant Name Duration

Intern:

BST OMS

SIG Year

6 Have you taken any significant absences (longer than 3 months) from your study or practice? If so, please provide details.

C. Referee Details

Name and address of CURRENT employer or hospital supervisor:

Name

Hospital

Address


Fax Email

Additional information may be sought from any person at any hospital named on the application form

2 List below the NAME and CURRENT EMAIL ADDRESS of four (4) consultants with whom you worked during the last 10 years during your training, and should include Consultants from intern/SIG rotations and if applicable OMS/Dental rotations.

Four (4) consultants will be selected by the Selection Committee from areas the applicant has worked in the previous five (5) years. For medical intern or resident posts please provide the name of the Head of Unit or Supervisor and listing all of the consultants or specialists in each unit is not required.

For OMS resident or dental resident / house surgeon posts please list all of your consultants including EMAIL ADDRESSES. Information required for a Professional Performance Appraisal may be sought from ALL or NONE of the consultants named.

i Name

Position & Specialty

Email Address

ii Name


Email Address

iii Name


Email Address

iv Name


Email Address

D. Declaration

I certify that information supplied in this application, for the purpose of processing my application for Surgical Training is true and correct. I understand that it may be disclosed to internal and external parties who provide administrative or organisational support to the process, or where the College is required to do so by law.

I understand that the Royal Australasian College of Dental Surgeons may wish to verify this information with institutions or individuals, and gather additional information in order to process my application. I agree to such inquiries being undertaken as part of the RACDS Surgical Training program eligibility process. I understand that if I fail to provide this information the College will be unable to process my application.

I understand that no further updates to this application will be accepted after the closing date of 5pm AEST on 16 May 2014.

I acknowledge that contact may be made with, and assessment scores may come from, anyone I have worked with in the last two years.

Signature: __________________________________ Date:__________________________

Unsigned applications will not be accepted.

You should lodge your application either in person or by mail with the College:

Royal Australasian College of Dental Surgeons

Level 13, 37 York Street, Sydney NSW 2000 Australia

Tel: (61) (2) 9262 6044 Fax: (61) (2) 9262 1974

Email: [email protected] Web: www.racds.org

Applications close 16 May 2014 [email protected]






ABN 97 343 369 579

For Office Use Only

FOMS10 - Oral and Maxillofacial Surgery Research Requirement

Trainee Name

Training Centre

Did the trainee commence BST (OMS) or OMS 1 after June 2009?

☐ Yes

Trainee has mandatory research requirements (see

below).

☐ No

This trainee does not have mandatory research

requirements as part of their completion of training.

MANDATORY REQUIREMENTS

☐ Post-graduate university research degree has been completed - date of completion

Institution: ____________________________________________________________________

Degree: ____________________________________________________________________

OR

☐ Research subcommittee assessment and approved study & research methodology course completed

Research Sub-committee requirements & methodology course:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Presentations:

☐ Present a paper each year at a scientific meeting, local ANZAOMS or RACDS meeting, a hospital grand

round, or

equivalent

AND

☐ Present a paper at the annual conference of ANZAOMS at least once during advanced surgical training

_______________________________________________________________________________________

☐ Trainee has satisfactorily completed the mandatory research requirements.

DIRECTOR OF TRAINING type or print name SIGNATURE: DATE



ABN 97 343 369 579

For Office Use Only

FOMS11 - Completion of Oral and Maxillofacial Surgery Training Program

EDUCATION OFFICER TO COMPLETE:

Trainee Name type or print trainee name

Training Centre tpye or print training centre

Current Hospital type or print hospital

BST (OMS) or OMS 1

Year Start - End , Location ______________________________________

OMS 2, 3, 4 years OMS 2 Start - End , Location ______________________________________

OMS 3 Start - End , Location ______________________________________ OMS 4

Start - End , Location ______________________________________

Has a total of 4 years

of training been

completed?

☐ Yes

Signature: insert electronic signature or sign ________________________

DIRECTOR OF TRAINING TO COMPLETE:

Training time completed as of:

insert date

Final Logbook summary – conclusion of training:

insert date

Satisfactory 6-month formative assessment for final term:

☐ Satisfactory insert date

☐ Unsatisfactory – if unsatisfactory please e-mail

[email protected] for further advice

Training portfolio reviewed and complete:

insert date

Mandatory research requirements:

☐ Not Required

☐ Required and Completed

☐ Required, Not Completed

I, type or print DoT name________________________________________________________, Director of Training of

insert training centre___________________________________________________________ certify that insert

trainee name________________________________________________________ has completed the training

requirements for the training pathway for the RACDS for the Fellowship in Oral & Maxillofacial Surgery FRACDS

(OMS).

Date: insert date_________________________________________________________________ Signature: insert electronic signature or sign ______________________________________________



OF DENTAL SURGEONS Incorporated

ABN 97 343 369 579

For Office

Use Only

SPECIALIST PRACTICE DISCIPLINE OF ORAL AND MAXILLOFACIAL SURGERY

FOMS 12 - Application for Assessment of Eligibility For Final Examination



Other Names

(Block Letters)

Date of Birth

_____ / ________ / _____

Day Month Year

Address for

Correspondence


Fax Email

Final Examination

Following a review of the training and level of competency in Oral and Maxillofacial Surgery, the

_______________________ Regional Surgical Committee RECOMMENDS / DOES NOT

RECOMMEND that the trainee be assessed by the Trainee Advisory Committee of the Royal

Australasian College of Dental Surgeons, for eligibility to sit the Final Examination in the Specialist

Practice discipline of Oral and Maxillofacial Surgery.

Director of Training (Name):____________________________

Maintenance of Learning Portfolio

The trainee has maintained a Learning Portfolio in accordance with the guidelines Appendix 1 of the

Handbook

Yes No

Applications will not be accepted without a Learning Portfolio.

Maintenance of Logbook

The trainee has maintained a Logbook of cases in accordance with the Handbook and Summary Sheets

until June of this year and have been forwarded to the College

Yes No

Applications will not be accepted without a Logbook and summary sheets.

Trainee Name in Full _______________________________________________________________

Signature ________________________________________

Date _________________

Director of Training

(Signature) ________________________________________ Date _________________

This form will not be accepted if it is not signed by the Director of Training. Fellowship is not

awarded until the trainee has completed their training program.

OMS 1 – (OMS – BST) Year Location

OMS 2 – (AST – 1)

OMS 3 – (AST – 2)

OMS 4 – (AST – 3)

I HEREBY apply for assessment of eligibility for examination in the Special Practice discipline of Oral and

Maxillofacial Surgery and enclose $569.00AUD being payment of the required fee.

NOTE: Candidates will be advised if their application is successful and a registration form and notification

of the examination fee will be sent.

Payment Product # 86

□ Cheque / Money Order / Bank Draft

Payable to the “Royal Australasian College of Dental

Surgeons”. Must be made in Australian Dollars drawn

on an Australian Bank.

□ Credit Card Payment (no GST)

Please debit my

credit card AUD$569.00 □ Visa □ Mastercard

Card Number

Expiry Date / ccv

Card Holder Name ____________________________________________________________

Signature ________________________________________ Date ________________

Closing date for receipt of this application is 1 May 2013

Disclaimer:

The College reserves the right to amend the timing and dates of examinations whenever conditions

warrant. Where examinations are cancelled or postponed, a full refund of the Examination

Registration fee will be issued. The College takes no responsibility for any other costs incurred by the

candidate.

CCV for Visa &


three digits of the



back of your card.

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