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*
Practice POC (Point of Contact)*

First NameLast Name
Practice POC Email*
example@example.com
Dental Office RDA Requirements*

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:
Operating Days*

MondayTuesdayWednesdayThursdayFridaySaturday
Operating Time*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Please Check What Applies*

Extern/Volunteer
Employment Status

Full-timePart-time
Starting Rate
Amount of Hours Requesting*
How did you hear about PDAA?*

Social MediaWebsite/GooglePrevious PDAA Graduate ReferralOther

Job Placement
Code
Placement Status
Student Name*

First NameLast Name
Hired?*

YesNo
Externship completed at this location?*

YesNo
Was a previous graduate assigned to this location?*

YesNo
Did this practice host an extern or hire our graduate?

Externship coordinated/assignedGraduate interviewed and hired
Notes
Should be Empty:

Externship Request