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Apply for nib's First Choice Network
ABOUT YOUR BUSINESS
Business (Trading) Name
What is your registered trading name?
Company Name (if applicable)
If you operate your business through a company, what is the company name?
If you are part of a larger dental group, what is the name of the dental group?
What is your ABN?
What is the registered address of your ABN?
HOW CAN NIB CONTACT YOU?
Contact Name (Authorised Representative)
Who is the person we should contact about joining the First Choice Network?
Contact Job Title
Contact email address
What is your postal address? If different from the practice address below
HOW DO NIB CUSTOMERS FIND YOU?
These are the details we will display to our customers to find you.
What is the name of the primary Practice Location that you would like to be a part of the First Choice Network?
Practice Address Line 1
Practice Address Line 2
Practice Web Address
Number of practice locations
How many practice location would you like to be part of the First Choice Network? (enter 1 or more?)
WHO CAN NIB CUSTOMERS SEE AT YOUR PRACTICE?
Practitioner Full Name
You can add multiple names in the field below
Practitioner Provider Number
You can add multiple provider numbers in the field below
You can add multiple specialties in the field below
By submitting your application you acknowledge nib's
terms and conditions