Laboratory Details



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Date01.02.2017
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DLA Application Form





Laboratory Details:


Telephone No:

Fax No:

Email:

Website:
MHRA No: CA __________________________________

Date Lab Established: ____________________________


Full Name of Laboratory Owner(s):





Type of Work Carried Out On Premises

 Implants

 Mouthguards

 Orthodontics

 Prosthetics

 Crown & Bridge

 Chromes

 Maxillofacial

 Other (please specify)




Type of Service:

 NHS Only


 Private Only


 Mix



Staff Profile – Please Specify the number of:

 Owner(s) GDC Registered

 Owner(s) Non-GDC Registered

 GDC Registered Dental Technician(s)


 Lab Assistant(s)

 Trainee(s)

 Others (Drivers, Admin Staff etc.)


Total:







Name of Registered Technician (s)

Registration Number

Registration Date

















































DLA Code of Practice

I/We (the undersigned) agree to abide by the DLA Code of Practice and I/We confirm that the above information given on this form is accurate and true. To be signed by Owners/Directors or Lab Manager
Signed …………………………………………..……….. Date …………….. PRINT NAME ………………………………………………..…………………………………………




Data Protection Act


The DLA will hold your personal data on its computer database and process it in accordance with the Act. This information may be accessed, reviewed and used by the DLA for administrative purposes (for example processing your membership application/renewal and contacting you in respect of your membership) and conducting market research. All of these purposes have been notified to the Information Commissioner.

Please tick if you do NOT want to receive offers and information about the DLA’s products and/or services. 



Please tick if you do NOT want to receive offers and information about other companies’ products and/or services. 


Please return this form together with a cheque for the £50.00 Administration Fee (Non-refundable) to:
Membership Department, Dental Laboratories Association, 44-46 Wollaton Road, Beeston, Nottingham, NG9 2NR or email to christine@dla.org.uk. Tel: 0115 925 4888 Fax: 0115 925 4800


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