New Account Form

Main Account Details

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* Company Name

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* Trading As

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* ABN

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* Practice Details

Address

Suburb

State

Post Code

Email Address

Email Address for Statements (If different from above)

Website

Phone Number

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* What type of practice are you?

General

Orthodontist

Prosthodontist

Endodontist

Oral Surgeon

Laboratory

Periodontist

Prosthetist

Other (please specify)

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* How many practitioners are in your practice?

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* Is your practice part of Corporate, Health fund, Group or Government Organization?

Yes

Please specify

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* Dentist authorised to use this account

Name

Mobile number

Email Address

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* Other dentist/s authorised to use this account (Please write N/A if not applicable)

Name 1

Name 2

Name 3

Name 4

Name 5

I certify that the above information is true and correct. I have read and understood the TERMS and CONDITIONS of Race Dental which form part of, and are intended to be read in conjunction with the New Account Form and agree to be bound by these conditions.

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* Signed

Name

Signature

Date

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* Designation of Signee

Proprietor

Partner

Director

Authorised Signatory