| Please print, fill out and mail or fax to Daily Dental Solutions, inc.
Name: _______________________________________________ Title: _________________
Maiden Name or Alias: _________________________________ Phone: ________________
Email: ____________________________ Alternate Phone: ___________________________
Address: ____________________________________________________________________
Date of Birth: ______________________ Date available to start: _______________________
Have you ever worked for or interviewed with DDS, inc.? ________ If so when? ___________
Days you are available: __ Mon __ Tues __ Wed __ Thurs __ Fri __ Sat
Areas you can work in: __ N OKC __ Edmond __ Guthrie __ S OKC __ Del City
__ Midwest City __ Mustang __Moore __ Norman __ Yukon __ ElReno __Shawnee
__ Chickasha __Newcastle/Tuttle __ Purcell __ Pauls Valley __ Stillwater __ Tulsa
__Woodward ___Enid __Ada __Duncan __Altus __Lawton ___Weatherford __Clinton
Other: ______________________________________________________________________
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What distance are you willing to drive one way?____________________________________
How much notice do you need?_____ Are you interested in last minute jobs?____
What is the earliest you can be called? (We generally will not call before 6 am) ____
What is the latest you can be called? (We generally will not call after 10 pm) _____
How many years of experience do you have in the dental field? _______ Please list the types
of practices you have worked in? ___________________________________________
____________________________________________________________________________
Front Office Support: Please specify all procedures you are comfortable in performing....
__ Scheduling __ Insurance File/Process __ Accounts Payable/Receivable __ Billing
__ Financial Arrangements __ Recall System __ Pegboard __ Case Presentation
__ Posting
Dentists, Registered Dental Hygienists and Dental Assistants you will need to provide us
a copy of your license/certificate. You will need to keep a copy with you at all times when
working as a temporary for Daily Dental Solutions, inc.
Do you have any expanded functions?
RDH: ___ Local Anesthesia ___ Nitrous Oxide
DA: ___ CDA ___ Radiation Safety ___ Coronal Polishing ___ Sealants ___ Nitrous
Have you used any of the following? __ Intraoral Camera __ Digital x-rays
____ Invisalign _____ Implants ____ Cerac ____ Fabricate Temporary Crowns
__ Computerized Charting: List software __________________________________________
__ Computer Experience: List programs __________________________________________
For DA: ___ Perio/Soft Tissue Charting ___ Existing/Hard Tissue Charting
Are there any procedures you are not comfortable performing?_________________________
If needed are you willing to help in other areas (if not busy)? __________________________
Has your license/certifications ever been revoked for any reason? ___ If so Why? _________
Have you ever been involved in a malpractice lawsuit? ____ If so Why? _________________
Please list 3 professional references (not family or former employers). Please give contact #.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Present & Previous Employment History (also include any temp work)
If applicable, may we contact your current employer? _______
#1 Employer Name ________________________________ City & State _______________
Phone # __________________________ Position Held _____________________________
Date of Hire ________________________ Last Day of Employment ____________________
Reason for leaving/termination __________________________________________________
#2 Employer Name _______________________________ City & State ________________
Phone # _________________________ Position Held _______________________________
Date of Hire ______________________ Last Day of Employment ______________________
Reason For Leaving/Termination _________________________________________________
#3 Employer Name ______________________________ City & State __________________
Phone # ________________________ Position Held ________________________________
Date of Hire _______________________ Last Day of Employment _____________________
Reason for Leaving/Termination _________________________________________________
IF not already listed, please provide a list of all dentists/dental offices employed by or temped for: __________________________________________________________________
Education:
College/University __________________________________________ State ____________
Dates Attended _____________________ Degree/Diploma/Certificate __________________
Are there any dental offices you will not work in & reason why: ________________________
____________________________________________________________________________
Please provide concise information regarding your skill & experience level. Include the type of
temporary work you are looking for (ex. Dentist, Dental Hygienist, Assistant, Front Office
Support, etc.) ________________________________________________________________
_____________________________________________________________________________
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Do you smoke? ________ Are you comfortable working with children?_________________
We do background checks on all applicants. Will you pass a background check? Please list any
misdeamenors or felony charges that may show up on your record. ________________________
I have completed this truthfully and to the best of my knowledge.
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Print Name & Title
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Signature Date
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