DDS, inc. Application for Temporary Work

Daily Dental Solutions, inc.

Email: Customerservice@dds4you.com

Office: 405-373-3299

Address: PO Box 594, Piedmont, OK 73078

www.DDS4you.com
Application for Temporary Work

Please complete the form below to apply to do Temporary work through DDS, Inc.
Full Name*

First NameMiddle NameLast Name
Maiden Name or Alias

First NameLast Name
Phone Number*
Current Address*

Street Address

CityState / Province

Postal / Zip CodeCountry
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Applying for Position*
Start date*

MonthDayYear
Date
Have you ever worked for DDS, inc? If so, when
Upload Resume*

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DENTIST, REGISTERED DENTAL HYGIENISTS AND DENTAL ASSISTANCE: You will need to provide a Copy of your license/ certificate. You will need to keep a copy with you at all times when working as a temporary for Daily Dental Solutions, inc. *

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OK Board License # or Permit # (Required for Dentists, Registered Dental Hygienists & Dental Assistants)*

OMS Assistant

DAANCE CertificationRadiation Safety/ X-rayCoronal PolishingSelentsNitrous OxideElder Care & Public HealthVaccination, Venipuncture & PhlebotomyAssist with Anesthesia
If needed, are you willing to help in other areas (if not busy)? *
Please list any dental procedures you are not comfortable performing. *
Please provide concise information regarding your skill & experience level. Include the type of temporary work you are looking for (Ex. Dentist, Dental Hygienist, Dental Assistant, Front Office Support, etc.)*
Have you ever been involved in a malpractice lawsuit? If so, please provide details regarding the lawsuit and any actions taken against you? *
Have you been disciplined by a Board of Dentistry (in any state)? Has your license/ certification through a Board of Dentistry ever been revoked for any reason? If yes to either question, please provide the State, date(s), any disciplinary actions taken, & explanation below. *
List any dentist or dental office you will not work in: *

List 3 professional references (not family or former employers). You can use friends, coworkers, people you have volunteered with, etc. Please list name, phone & email address.
#1 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
#2 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
#3 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com

Present & Previous employment History (also include any temp work)
If applicable, may we contact your current employer? (We will contact all previous employers to verify work history).*
#1 Employer Name*
Phone Number*
Please enter a valid phone number.
City & State*
Position Held*
Date of Hire*

MonthDayYear
Date
Last Day of Employment

MonthDayYear
Date
Reason for Leaving/ Termination.
#2 Employer Name
Phone Number
Please enter a valid phone number.
City & State
Postion Held
Date of Hire

MonthDayYear
Date
Last day of employment

MonthDayYear
Date
Reason for Leaving/ Termination
#3 Employer Name
Phone Number
Please enter a valid phone number.
City & State
Postion Held
Date of Hire

MonthDayYear
Date
Last day of employment

MonthDayYear
Date
Reason for Leaving/ Termination.
If not already listed, please list all other dentist/ dental offices employed by or temped for:

Do you smoke or use tobacco products?*
Are you comfortable working with children? *
Will you be able to pass a background check? Please list any misdemeanor or felony charges that may show up on your record. *
Signature*

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