Membership Application ⇽ DY5-2023 - Dental Student Year 5 2023

Glue Up account creation information.

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Profile Photo

Please enter a first name

First Name *

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Please enter a last name

Last Name *

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Please enter a valid email address
e.g. john.doe@glueup.com

Email Address *

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・8 characters minimum
・one upper case letter
・one lower case letter
・one number
・one special character (@$!%*?&)

Password *

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・8 characters minimum
・one upper case letter
・one lower case letter
・one number
・one special character (@$!%*?&)

Confirm password (at least 8 characters) *

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Please fill in your member application details.

Please enter a first name

First Name *

If you input more than 0 characters your First Name may not display properly

Please enter a last name

Last Name *

If you input more than 0 characters your Last Name may not display properly

Please enter a valid email address
e.g. john.doe@glueup.com

Email *

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Please enter a valid phone number including country code

Phone

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Company

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Title/Position

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DENTAL PROTECTION Membership Application Form

Oral Health Care Professionals wishing to apply to become a DENTAL PROTECTION member are required to create a profile by completing the following information.

When logging into the self-serve platform with the details provided you shall be able to further edit your profile and supply additional information should it be required.

Depending on your mail settings e-mail communications may be in your junk file, if not received call the SADA office at 011 484 5288 or email dpmembership@sada.co.za for assistance.

Please enter a professional number

Professional Number *

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Maximum limit reached (255 characters).

Title

Please enter a initials

Initials *

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Please enter a first name

First Name *

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Middle Name

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Please enter a surname

Surname *

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Known As

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Maiden Name

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Please enter a valid date
e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

Date of Birth *

Please enter a id/passport number

ID/Passport Number *

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Please enter a postal address line 1

Postal Address Line 1 *

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Please enter a valid phone number including country code

Landline (Practice)

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Postal Address Line 2

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Please enter a valid phone number including country code

Mobile (Private) *

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Please enter a postal address suburb

Postal Address Suburb *

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Please enter a valid email address
e.g. john.doe@glueup.com

Email (Private) *

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Please enter a postal address town/city

Postal Address Town/City *

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Please enter a postal address postal code

Postal Address Postal Code *

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Please enter a postal address province

Postal Address Province *

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Please enter a postal address country

Postal Address Country *

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Qualification1

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Please enter a valid date
e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

Year1

University1

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Please select an option

Speciality *

Please select an option

SADA Membership Type *

Please select an option

SADA Branch *

DP Reg #

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Please enter a valid date
e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

DP Start Date

Please enter a valid date
e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

DP End Date

DP Code

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DP Designation

To include Dental Protection membership in your application please follow this link

https://www.dentalprotection.org/south-africa/join

Glue Up account creation information.

Please fill in your member application details.

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