Race Rewards Registration Form Survey

Do you have an existing Race Dental account?(Required.)

Yes

No

Name of your Account Manager(Required.)

Keren Lukanovic

Buba Adamchevska

Artem Shtaltovoy

I don't know

If you answered Yes above, kindly indicate your Race Dental account number

Company/Practice Name

Trading As

ABN

Practice Details(Required.)

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Website

What year was your practice established?(Required.)

Is your practice a Private Practice, part of Corporate, Health fund, Group or Government Organization?

Dentist authorised to use this account

Name

Mobile number

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

Alternative practice contact (i.e. Practice Manager)

Name

Position

Contact Number

Email Address

What is your estimated monthly lab spend?

$ 1, 000 AUD

$ 2, 000 AUD

$ 4, 000 AUD

$ 8, 000 AUD

Who do you send your lab work to?

DETAILS OF ADDITIONAL PARTNERS AND / OR DIRECTORS

Name

Home Address

Email Address

Phone Number

Would you like to register to Race Rewards?

Yes

No

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 Race Rewards Registration Form and agree to be bound by these conditions.

Signed

Name

Signature

Date

Designation of Signee

Proprietor

Partner

Director

Authorised Signatory