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

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* Entity Type

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* What year was your practice established?

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* What type of practice are you?

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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?

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* Dentist authorised to use this account

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

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* Alternative practice contact (i.e. Practice Manager)

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* What services are relevant in your practice?

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* What is your estimated Race Dental monthly lab spend?

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* What is your estimated monthly lab spend with other laboratories?

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* How did you hear about us?

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* DETAILS OF ADDITIONAL PARTNERS AND / OR DIRECTORS

I certify that the above information is true and correct. I have read and understood the GENERAL TERMS and CONDITIONS OF TRADE 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

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* Designation of Signee

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