Dental Assistant Application
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Educational Qualifications Certifications & Credentials
Are you a Registered Dental Assistant (RDA)?
*
Yes
No
Do you hold a valid California Radiation Safety license?
*
Yes
No
Do you hold a valid California Infection Control Course?
*
Yes
No
Do you hold a valid California Coronal Polishing Course?
*
Yes
No
Are you certified in CPR?
*
Yes
No
Please Upload All your Certificates (Optional)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Work Style & Preferences
What type of work environment do you thrive in?
*
Fast-paced
Calm & Organized
Team-Oriented
Independent
Are you open to working weekends or evenings if needed?
*
Yes
No
What is your ideal schedule?
*
Full Time
Part Time
Specific Days
Which Days you can work?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What is your expected hourly wage?
*
When can you start?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you prefer working in a general dental office or a specialty practice?
*
General
Ortho
Endo
Perio
Pedo
Surgical
Pediatric
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Scenario-Based & Personality Questions
Are you applying for Dental School?
*
Yes
No
Are you interested in Dental office Front Desk work?
*
Yes
No
Please verify that you are human
*
Submit
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