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* Do you have an existing Race Dental account?

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* Name of your Account Manager

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

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* Company/Practice 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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* Type of Practice

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* Number of practitioners in your practice

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* Is your practice a Private 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 monthly lab spend?

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* Who do you send your lab work to?

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* DETAILS OF ADDITIONAL PARTNERS AND / OR DIRECTORS

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* Would you like to register to Race Rewards?

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.

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* Signed

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* Designation of Signee

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