Race Rewards Registration Form

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* Do you have an existing Race Dental account?

Yes

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* Name of your Account Manager

Keren Lukanovic

Buba Adamchevska

Artem Shtaltovoy

I don't know

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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

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Website

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* Entity Type

Sole Trader

Partnership

Trust

Corporate Entity

Proprietary Company

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* What year was your practice established?

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* Type of Practice

Dental Practice

Laboratory

Prosthetist

Ortho

Prosthodontist

Endodontist

Oral Surgeon

Periodontist

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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?

Private Practice

Corporate

Health fund

Group

Government Organization

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* Dentist authorised to use this account

Name

Mobile number

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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

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

Name

Position

Contact Number

Email Address

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* What services are relevant in your practice?

Crown, Bridge, Veneers

Orthodontics

Splints

Mouthguards

Implants

Acrylic

Chrome

Race Rewards Program

Race Academy Education

100% Australian Made Preference

Other (please specify)

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* What is your estimated monthly lab spend?

$ 1, 000 AUD

$ 2, 000 AUD

$ 4, 000 AUD

$ 8, 000 AUD

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* Who do you send your lab work to?

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* DETAILS OF ADDITIONAL PARTNERS AND / OR DIRECTORS

Name

Home Address

Email Address

Phone Number

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* Would you like to register to Race Rewards?

Yes

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

Name

Signature

Date

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* Designation of Signee

Proprietor

Partner

Director

Authorised Signatory