Pure Dental Academy - Extern Student Work Request

Externship Request
Practice Name*
Select The Referral Campus*
Select the campus that's closest to your practice for student commute purposes.
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
Format: (000) 000-0000.
Practice POC (Point of Contact)*

First NameLast Name
Practice POC Email*
example@example.com
Open DentalDigital x-raysSterilizationProcedure Set-UpImpressions/LabChair Side AssistingDisinfect and Set-Up of OpsPolish and Floss/OHI
Office Dental Assistant Requirements*
Please list the office's hours and days of operation below:
MondayTuesdayWednesdayThursdayFridaySaturday
Operating Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Extern/Volunteer
Full-timePart-time
Starting Rate
Amount of Hours Requesting*
Social MediaWebsite/GooglePrevious PDAA Graduate ReferralOther
- Code
- Placement Status
- Student Name*
  
  First NameLast Name
- YesNo
- YesNo
- YesNo
- Externship coordinated/assignedGraduate interviewed and hired
- Notes
- Should be Empty:

Externship Request