Name
Program
Company Name
Employer Address
Start Date
End Date
Currently Employed Yes
Employer Phone Number
Supervisor's Name
Supervisor's Email
Your Position / Title
List of Job Duties (Please select all that apply) Dental AssistingVitalsPrepare patients and the work area for treatments and proceduresKeep records of dental treatmentsChairside AssistingSterilize dental instrumentsDry patients’ mouths using suction hoses and other equipmentScheduling AppointmentsAssisting DentistChartingAssist in Dental ProceduresRooming patientsPatient educationPatient recordsClinical dutiesProcess x rays and complete lab tasks, under the direction of a dentist
Hours Per Week
Wage
Signature
My Electronic signature certifies all the information above as true and correct to the best of my knowledge. Part Time/Temporary Work Statement: My electronic signature above indicates my choice to seek or accept part time work. Part time work is defined as at least 20 hours per week for 5 weeks (35 calendar days)
Today's Date
