AOHT Membership Application (Ordinary / Associate) * First Name * Last Name * DCR No. * Contact No. * Date of Birth * Citizenship * AddressPreferred mailing address * Email * Company Name and Address * Education Institution * Qualification/Year of Graduation * PasswordStrength: Very WeakDeclaration for QBE Indemnity (Ordinary Members Only) Have you ever been subjected to disciplinary proceedings for professional misconduct?YESNOHave any claims for negligence or breach of professional duty been made in the last ten (10) years against you or have circumstances been notified to insurers that might give rise to a claim?YESNOAre you aware of any claims or circumstances that might give rise to a claim which is not referred to in the Question above?YESNOIf yes for any of the above, please email to secretariat@aoht.org.sg Supporting Documents and Payment Supporting documents to be submitted (hard or soft copy): For ORDINARY membership: Practising Certificate For ASSOCIATE membership: Identity Card / Passport / Qualification Certificate/ Student Matriculation Card OR Practising Certificate (where applicable) Supplemental Consent I hereby agreeTo receive newsletters and upcoming event(s) details and related information.I hereby agree:To receive emails with regards to job opportunities and related information.* I hereby agreeTo disclose my personal information to QBE for the purpose of Dental Indemnity.Disclaimer * DisclaimerI certify that my answers are true and complete to the best of my knowledge.* DisclaimerI understand that false or misleading information in my application may result in cessation of AOHT membership and QBE Indemnity coverage without notice.SubmitDone(Use Cropper to set image and use mouse scroller for zoom image.)