www.gdc-uk.

org

Registering as a dentist with the General

Dental Council (EU/EEA/Switzerland)

Application Form

This application form, accompanying documents and registration fee should be posted to:

Registration Team (New Registrations)

General Dental Council
43-45 Portman Square
London
W1H 6HN

Dentist registration application form March 2016 v12

(EU/EEA/Switzerland)
Section 1: Registration details (Please complete in BLOCK letters)
The details that you enter in this section will be your registered details. Your name, registered
address, and your qualification(s) will appear in the register and will be available to the public
on our website or on request. We will not disclose to the public any other personal details you
provide.

Registration number: (office use only)

Title: Mr Mrs Ms Miss

Last name:

First names:

Address:

Postcode:

Gender: M F

Date of birth:
D D M M Y Y

Nationality:

Other contact details

To ensure we are able to process your application promptly, please provide contact telephone
numbers and an email address. These details will not be made available to the public.
From time to time we may wish to contact you by email or text message.

Home phone:

Work phone:

Mobile phone:

Email address:

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Primary dental qualification Awarded by Year qualification gained

The above details are correct and my name has not been entered in the dentists register before

Signed: Date:

Return of documents

Please tick if you would you like your documents returned. There is a 10 fee,
payable by debit/credit card online through eGDC at the time the registration fee
is paid.

Amendments countersigned

Any amendments made on the application form or supporting documents must

be countersigned. Do not use correction fluid.

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Section 2: Character Reference
Character Reference (See guidance notes)
The character reference must be completed by someone who has known the applicant for at
least a year and must not be a member of the applicants family.

The character referee must also sign the back of the passport photograph. By doing so, they are
certifying that the image is a true likeness of the applicant.

I (insert full name of character referee):

professional position:

of (insert address):

Postcode:

have completed this declaration in respect of:

(insert name of applicant):

And either: (Please tick one of the boxes below)

(a) am satisfied that, to the best of my knowledge that they are of good character and fit for
registration

OR

(b) the GDC should be aware of the following details of character which might affect their
suitability for registration (please use a separate sheet if required).

Signed: Date:

This certificate is only valid for three months from the date on which it was signed

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Section 3: English Language

The Dentists Act 1984 requires the GDC to be satisfied that all applicants have the necessary knowledge
of English prior to entry to our registers.

Please refer to our Evidence of English language competence: guidance for applicants document,
which can be found on the GDCs website www.gdc-uk.org. This sets out how and when we will request
evidence or information to determine whether you have the necessary knowledge of English and the
process we will follow.

Please provide with this application recent, objective evidence that you can read, write and interact
effectively in English with patients, relatives and other healthcare professionals in relation to your role as
a dental professional.

I confirm that I have read and understood the English language requirements and that I may be
asked to provide evidence following recognition of my qualifications.

Please tick: Yes

Please tick as appropriate the evidence that you are submitting:

International English Language Testing System (IELTS) certificate

A recent primary dental qualification that has been taught and examined in English

A recent pass in a language test for registration with a regulatory authority in a country where the
first and native language is English

Recent experience of practising in a country where the first and native language is English

Other (please provide details in the box below)

Section 4: Health, Character, Indemnity and Self-Declaration (See guidance notes)

Before answering the first two questions, please read the GDCs health self-certification guidance.

1. Are you a carrier of any infectious disease, blood-borne virus or other transmissible disease or do
you have any reason to believe that any such infectious or transmissible disease may be present

Yes No

If yes, please give details of the infectious or transmissible disease or blood-borne virus on a separate
sheet.

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2. Do you have any health condition which may affect or has affected the safety of patients you treat
and/or those you work with, and/or your ability to do your job safely?

Yes No

If yes, please give details of the medical condition on a separate sheet. If the GDC has any concerns
about your health, we may need to obtain further information from any medical practitioner who is
treating you. If you have answered yes to any of the statements above, please provide the full name and
contact details for your occupational health practitioner and/or any other medical practitioner who is
treating you.

3. Have you been convicted of a criminal offence and/or cautioned (other than a protected conviction or
caution) and/or are you currently the subject of any police investigations which might lead to a
conviction or a caution in the UK or any other country?

Note: Dentists are exempt from The Rehabilitation of Offenders Act 1974. You must therefore tell us
about prosecutions or convictions, including those that might otherwise be considered spent under
this act (other than a protected conviction or caution). Protected convictions and cautions are defined
in the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and
Wales) Order 2013.

Yes No

If yes, please give details on a separate sheet, including the approximate date, offence, authority which
dealt with the offence and any circumstances that you would want the Council to be aware of in
consideration of your application.

4. To the best of your knowledge, have you been or are you currently subject to any proceedings by a
regulatory or licensing body in the UK or any other country?

Yes No

If yes, please give details on a separate sheet of the nature of the proceedings undertaken, or
contemplated, including approximate date of proceedings, country where proceedings were
undertaken and the name and address of the licensing or regulatory body concerned.

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5. Declaration by all applicants

I consent to you contacting my character referee and give consent to contact any of the health
practitioners whose names have been provided.

The Dentist Act 1984 includes a legal requirement for registrants to hold insurance or indemnity cover for
practising as such.
I have in place, or will have in place at the point at which I practise in the UK, insurance or
indemnity arrangements appropriate to the areas of my practice.
Please tick: Yes
Making a false declaration to the GDC is a serious issue. If you declare that you have or will have
appropriate indemnity in place and this is found to be false, there is a risk that you may be subject to
fitness to practise proceedings or removed from the GDC register.

I will advise the GDC of any future criminal proceedings/police investigations, convictions or cautions
and any future health conditions which arise which affect the safety of patients I treat and/or those they
work with, and/or my ability to do my job safely.

I have read and understand the General Dental Councils standards and health self-certification
guidance and I will adhere to this guidance.

The information I have given here is true.

Signed: Date:

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Section 5: Payment for this application only

I wish to pay by: (please tick)

Credit / Debit Card

Credit / debit card payments can only be made on our e-payment portal.

We will notify you by email when you can make the payment. This will normally be when your
application has been processed and we can proceed with your registration.

In order to pay by credit or debit card you must have access to the internet and an email account.

Please provide the following details so that we can contact you. Please ensure that you check your
email account regularly and contact us should your email address or phone number change.

Please make payment within 14 days of receiving your payment request form, otherwise your
application may be delayed or returned to you.

Email address:

Preferred contact telephone number:

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Payment for future annual retention fees (ARF)
Bank/Building Society to pay by Direct Debit

Please complete this form if you wish to pay your future annual retention fees by Direct Debit. The
completed form must be received by 30th September of the year prior to the year you are paying for.

Please complete form in BLOCK CAPITALS using a ball point pen

Name(s) of Account Holder(s) to be debited

Bank or Building Society Account No

Branch Sort Code

Name and full postal address of your United Kingdom Bank or Building Society

Direct Debit Originators No

7 5 8 5 7 8

Your GDC registration number (for office use only)

Instruction to your Bank or Building Society: Please pay the General Dental Council Direct Debits
from the account detailed on this instruction subject to the safeguards assured by the Direct Debit
Guarantee. I understand that this instruction may remain with the General Dental Council and if so,
details will be passed electronically to my Bank/Building Society.

Signature of account holder(s): Date:

Signature of account holder(s): Date:

Banks and Building Societies may not accept Direct Debit instructions for some types of account.

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Please detach and retain this guarantee.

The Direct Debit Guarantee

This Guarantee is offered by all banks and building societies that accept instructions to pay
Direct Debits.

If there are any changes to the amount, date or frequency of your Direct Debit the General
Dental Council will notify you 10 working days in advance of your account being debited or as
otherwise agreed. If you request the General Dental Council to collect a payment, confirmation
of the amount and date will be given to you at the time of the request.

If an error is made in the payment of your Direct Debit by the General Dental Council or your
bank or building society you are entitled to a full and immediate refund of the amount paid from
your bank or building society

- If you receive a refund you are not entitled to, you must pay it back when the General Dental
Council asks you to.

You can cancel a Direct Debit at any time by simply contacting your bank or building society.
Written confirmation may be required. Please also notify us.

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CHECKLIST for dentists qualified in the EEA
Please follow the checklist below and ensure you have completed all relevant sections of the
application form and included all required documents. Incomplete applications or documents
which do not meet the GDCs standards may not be accepted and may be returned to you.

Section 1: Registration details

Have you provided your name, contact details and primary dental qualification
details? Have you signed and dated the form?

Section 2: Character reference

Has your referee signed and dated the form and the back of your passport
photograph? Your referee must have known you for at least a year and must not be
a family member. If applying within one year of graduation, this must be completed
by the dean or head of your dental training school.

Section 3: English Language

Have you read the requirements for English language and provided any relevant
evidence? Please refer to Evidence of English language competence: guidance for
applicants document, which can be found on the GDC website (www.gdc-uk.org) for
types of evidence we are likely to accept as demonstrating that a dental professional
has the necessary knowledge of English.

Section 4: Health, Character and Indemnity Self-Declaration

This section must be completed and signed by you. Ensure you have also ticked the
box.

Section 5: Payment for this application only

Have you provided contact details to pay by credit/debit card?

Section 6: Payment for future annual retention fees (ARF)

Have you decided to pay the ARF by Direct Debit in future? If so, have you provided
the relevant information? Please note that you can only do this if you have a UK bank
account

Guidance notes
Have you read the document Guidance for dentists qualified in EEA and specific
guidance for the country where you qualified?

Equality monitoring form

The information you provide helps us ensure our policies and procedures do not
discriminate.

Amendments countersigned
Any amendments made on the application form or supporting documents must be
countersigned. Do not use correction fluid.

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 Equality Monitoring Form
The GDC is committed to promoting and developing equality and diversity in all our
work. We want to be sure that our policies and ways of working are fair and do not
discriminate against individuals or groups. To help us to monitor the effectiveness of
our policies and practices we ask you to complete the monitoring form. This information will be treated in the strictest confidence under the
Data Protection Act 1998 and will be used to produce statistics to enable the GDC to look at the diversity profile of our staff, registrants and
others with whom we work. Through this we can check a variety of processes to ensure equality and address issues as they arise.

AGE
16-21 22-30 31-40 41-50 51-60 61-65 Over 65 Prefer not to say
DISABILITY Do you consider yourself to have a disability?
Yes No Prefer not to say
(The Equality Act 2010 defines disability as a physical or mental impairment which has substantial long-term effect on a persons ability to carry out
normal day to day activities.)

RACE
White Black or Black British
British African
Irish Caribbean
Any other White background (please specify) Any other Black background (please specify)

Asian or Asian British Mixed Ethnic Background

Bangladeshi White and Asian
Indian White and Black African
Pakistani White and Black Caribbean
Any other Asian background (please specify) White and Chinese
Any other mixed ethnic background (please specify)
Chinese or any other ethnic group
Chinese
Any other ethnic background (please specify) Prefer not to say

SEX
Female Male Prefer not to say
GENDER IDENTITY is your gender identity the same as the gender you were assigned at birth?
Yes No Prefer not to say
RELIGION/BELIEF
Buddhist Christian Hindu None
Jewish Muslim Sikh Prefer not to say
Other religion / faith (please specify)
SEXUAL ORIENTATION
Bisexual Gay man Gay woman Heterosexual Prefer not to say
MARITAL STATUS
Civil partnership Divorced Married
Separated Single Widowed Prefer not to say
THANK YOU FOR YOUR COOPERATION