Membership Application Form

In order to manage, oversee and administer the operations of Denturist Association of Ontario (“DAO”) and to evaluate your eligibility for membership in DAO, DAO is required to collect, disclose, retain and otherwise process certain personal information about you (“Personal Information”) including, but not limited to, your name, address and telephone number and information about your education, credentials and professional history. DAO may also collect Personal Information about you from The College of Denturists of Ontario in order to assist with the administration of DAO and to process your membership application. When you become a member of DAO or when you renew your membership in DAO, you automatically receive membership in the Denturist Association of Canada (DAC).  DAO may share your Personal Information with DAC so that you can receive communications from DAC about your DAC membership and about DAC services, as well as a subscription to Denturism Magazine. DAO may collect Personal Information from or disclose Personal Information to such insurance broker, professional liability insurance provider and other group benefits providers as DAO may have in place from time to time, in connection with your professional liability insurance coverage and other group benefits.

By completing this application form, you are authorizing DAO to collect, use, disclose and retain your Personal Information for the purposes and in the manner described above. Please also refer to our Privacy Policy for more information about how we collect, use and disclose Personal Information.

ANY CONCEALMENT, MISREPRESENTATION OR FALSE DECLARATION IN THIS FORM OR IN ANY SUPPORTING DOCUMENTATION COULD CAUSE YOUR APPLICATION FOR MEMBERSHIP TO BE REJECTED OR YOUR MEMBERSHIP TO BE TERMINATED.

Registration Information for
the College of Denturists of Ontario (CDO)

Primary Clinic Information

If you do not currently have Clinic Information, please add HOME / ALTERNATE ADDRESS as the Clinic Name, and provide your mailing address in this section.  Subsequently, select NO below where asked Is this your mailing address? And repeat the necessary information in the fields provided.  This will save your information accordingly in your member profile.

Professional Liability Insurance

If you are interested in obtaining PLI through the DAO Group Policy, you will be asked to download the BMS Insurance Group Application and to upload the completed form in order to complete the online DAO Member Application.

Please download the BMS Insurance form and upload a filled form.

I hereby acknowledge and confirm that:

• I have read and understood this form.
• All information I have entered is true and accurate.
• I am a qualified denturist registered with the College of Denturists of Ontario to practise denturism in Ontario.
• I agree to pay the applicable membership fees as set out above

I have reviewed this form and DAO’s Privacy Policy, which explain what Personal Information is collected by DAO, why it collects it, to whom it discloses it and how it uses it. I understand that DAO is seeking my consent to collect, use and disclose my Personal Information for the purposes of evaluating my application to be a Member of DAO, to administer, implement and manage my membership and to comply with legal and regulatory requirements. I understand that I may refuse to give my consent or that I may later withdraw my consent, and that if I refuse or withdraw my consent, DAO will be unable to process my application.

I hereby voluntarily consent to the collection, use and disclosure of my Personal Information, as described in this form and in DAO’s Privacy Policy.

I hereby authorize DAO, DAC, The College of Denturists of Ontario, DAO’s brokers, insurer, group benefits providers and any other third parties that may assist DAO (now or in the future) with administering or managing DAO or its membership services, administration or benefits processes, to collect, use, disclose, retain and transfer my Personal Information, in electronic or other form, for the purpose of evaluating my membership application and for implementing, administering and managing my membership in DAO and providing me with membership services and group benefits. I understand that my Personal Information will be held only as long as is necessary to implement, administer and manage my membership in DAO and to provide me with membership services and group benefits.

I declare that my answers given in this Membership Application are full, true, accurate and complete and that they contain no untrue or misleading statement nor any omission of a material fact. I UNDERSTAND THAT ANY CONCEALMENT, MISREPRESENTATION OR FALSE DECLARATION IN THIS FORM OR IN ANY SUPPORTING DOCUMENTATION COULD CAUSE MY APPLICATION FOR MEMBERSHIP TO BE REJECTED OR MY MEMBERSHIP TO BE TERMINATED.

I agree to abide by the Code of Ethics of the Denturist Association of Ontario as amended or replaced from time to time, which outlines the general principles of conduct, duties and responsibilities to which members of the Association are expected to adhere in their relationships with the public, with their patients and with their fellow practitioners.

I understand that my electronic signature on this application form, including faxed versions of an original signature or electronically scanned and transmitted versions, including, without limitation, “pdf”, “tif” or “jpg, of an original signature, or my use of a key pad, mouse or other device to select an item, button, icon or similar act/action, constitutes my signature, acceptance and consent as if actually signed by me in writing, and that it will have the same force and effect as a handwritten signature.  I acknowledge that my electronic signature shall be binding and shall have the same legal force and effect as my handwritten signature.