PMC Dental Application

Last Name First Name Middle Initial

Address

City State Zip

Phone 1st Phone 2nd

E-mail

Have you ever been arrested? ---YesNo

Convicted of a Crime?---YesNo

If YES in Arrested and/or Convicted; Must give all dates and details below.

Answering YES to above questions does not necessarily disqualify you from employment.

Dental position applying for?

Check if Licensed/Certified in the State of Michigan for:
 EFDA X-Ray CPR Certified ORTHO Certified

If a Dentist or Hygienist, Michigan license number:

Michigan X-Ray License #

Any experience in the specialty field(s)?
 Oral Surgery Ortho Perio Endo Pedo Prostho

Your Skills:
 Take X-Rays Panoramic Bitewings Full Mouth Digital Ceph. OSHA Prescribed Sterilization Temporary Crowns Polycarbonate Acrylic Tin Post Operative Instructions Preliminary Oral Exam Four-Handed Chairside Oral Hygiene Instructions Charting Perio Charting Administering Topical Fluorides Soft Tissue Management Alginate Impressions Polishing Coronal Crowns Periodontal Training Oral Health Instructions Applying Pit/Fissure Sealants Filling out Insurance Forms Applying Topical Anesthetic Placing/Removing Temp Crowns/Restoration Daily Reconciliation Suture Removal Assisting in the Administration of NO Daily Deposit Apply Cavity Liners/Bases Placing/Removing Periodontal Dressing Schedule Appointments Placing/Removing Rubber Dam Placing Tofflemire Matrix Retainers Computer Literate Operate Autoclave Operate Dryclave Ultrasonic Disinfection

Programs Used:

Bilingual:---YesNo if yes,

Please print and complete the following forms and return to Dental Staffing at the address below. Your prompt attention will help prevent payroll delays.

OR

  I will only accept work as an independent contractor, be in control of my own hours, schedule and performed duties.

I FULLY UNDERSTAND THIS MAY AFFECT HOW MUCH WORK IS REFERRED TO ME AND WILL BE CONSIDERED A REFUSAL OF WORK IN CERTAIN CASES.

By typing my name below, I affirm that all information submitted on this application is true and correct.

Employee's electronic signature

Upload Resume:

Please fax or mail copies of the following:

1. Dental/Hygiene License (if applicable)
2. CPR Card
3. X-ray Certification/License (if applicable)
4. Expanded Functions Certification (if applicable)
5. Orthodontics Certification (if applicable)
6. Drivers License/Identification Card
7. Social Security Card
8. Resume
9. Letters of recommendation (if applicable)