| Name: _______________________________________________________________________ Address: ____________________________________________________________________ Phone: ____________________________ Alternate Phone: ____________________________ Email: ______________________________ What Position are you looking for? _________________________________________________ How much experience do you have in this position? ____________________________________ Dentists ONLY: Do you currently have: Oklahoma License ______ DEA License ______ Narcotic License _______ Malpractice Insurance ________ Registered Dental Hygientist Only: Oklahoma License ______ How long have you been licensed in the state of Oklahoma? _______ Is this a Temporary or Permanent License? _______ Are you licensed for Local Anesthesia and/or Nitrous Oxide Administration? ______ Dental Assistants Only: Please indicate any certifications you have for expanded functions... CDA Radiation Safety Coronal Polishing Sealants Nitrous Oxide Front Office Support Only: What dental softwares are you familiar with: Dentrix SoftDent EZDental EagleSoft Dental.com WinDent Other: _______________________________________________________________________ Please indicate the procedures you proficient in: ___ Scheduling ___ Insurance File/Process ___ Accounts Payable/Receivable ___ Billing ___ Financial Arrangements ___ Recall ___ Pegboard ___ Case Presentation ___ Posting To All Applicants: Are there any specific areas you are interested in working in? North OKC Edmond Guthrie Bethany Yukon El Reno South OKC Moore Norman Noble Chickasha Lawton Purcell Shawnee Midwest/Del City Mustang Blanchard Pauls Valley Tulsa Jenks Ponca City Enid Stillwater Woodward Clinton Ada Weatherford Duncan Altus Muskogee Tahlequah Bartlesville Ardmore McAlester Other: _______________________________________________________________________ Many offices now offer early or late hours for patients. Are you interested in positions that start early in the morning?_________ Are you interested in offices that offer late appointments? ______ Are there benefits you are looking for in a position? Please Specify _________________________ _____________________________________________________________________________ What days are you looking for employment? _________________________________________ Are you flexible on the days? _______ Are you looking for Part-time or Full-time? _____________ When accepting a permanent position through Daily Dental Solutions, inc. it is your express responsibility to inform us immediately if you are released or resign from the said position. Please send us a current resume. If possible please include it on floppy or CD. We reserve the right to verify previous employment & references, as well as, make any needed changes to your resume. ______________________________ _____________________________ ____________ Print Name Signature Date
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