Externship Request
Practice Name
*
Select The Referral Campus
*
Please Select
PDAA - Irving
PDAA - Mesquite
PDAA - Houston
Select the campus that's closest to your practice for student commute purposes.
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practice Phone Number
*
Format: (000) 000-0000.
Practice POC (Point of Contact)
*
First Name
Last Name
Practice POC Email
*
example@example.com
Dental Office RDA Requirements
*
Open Dental
Digital x-rays
Sterilization
Procedure Set-Up
Impressions/Lab
Chair Side Assisting
Disinfect and Set-Up of Ops
Polish and Floss/OHI
Office Dental Assistant Requirements
*
Please list the office's hours and days of operation below:
Operating Days
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Operating Time
*
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Please Check What Applies
*
Extern/Volunteer
Employment Status
Full-time
Part-time
Starting Rate
Amount of Hours Requesting
*
How did you hear about PDAA?
*
Social Media
Website/Google
Previous PDAA Graduate Referral
Other
Submit
Job Placement
Code
Placement Status
Please Select
Placed
Pending
Student Name
*
First Name
Last Name
Hired?
*
Yes
No
Externship completed at this location?
*
Yes
No
Was a previous graduate assigned to this location?
*
Yes
No
Did this practice host an extern or hire our graduate?
Externship coordinated/assigned
Graduate interviewed and hired
Notes
Submit
Should be Empty: