| Name: _______________________________________________________________________
Address: ____________________________________________________________________
Phone: ____________________________ Alternate Phone: ____________________________
Email: ______________________________
What Position are you looking for? _________________________________________________
How much experience do you have in this position? ____________________________________
Dentists ONLY:
Do you currently have: Oklahoma License ______ DEA License ______
Narcotic License _______ Malpractice Insurance ________ SoonerCare ________
Registered Dental Hygientist Only:
Oklahoma License ______ How long have you been licensed in the state of Oklahoma? _______
Is this a Temporary or Permanent License? _______ Are you licensed for Local Anesthesia and/or
Nitrous Oxide Administration? ______
Dental Assistants Only: Please indicate any certifications you have for expanded functions...
CDA Radiation Safety Coronal Polishing Sealants Nitrous Oxide OK Permit
Front Office Support Only: What dental softwares are you familiar with:
Dentrix SoftDent EZDental EagleSoft Dental.com WinDent
Other: _______________________________________________________________________
Please indicate the procedures you proficient in: ___ Scheduling ___ Insurance File/Process
___ Accounts Payable/Receivable ___ Billing ___ Financial Arrangements ___ Recall
___ Pegboard ___ Case Presentation ___ Posting
To All Applicants: Are there any specific areas you are interested in working in?
North OKC Edmond Guthrie Bethany Yukon El Reno South OKC
Moore Norman Noble Chickasha Lawton Purcell Shawnee
Midwest/Del City Mustang Blanchard Pauls Valley Tulsa Jenks
Ponca City Enid Stillwater Woodward Clinton Ada Weatherford
Duncan Altus Muskogee Tahlequah Bartlesville Ardmore McAlester
Other: _______________________________________________________________________
Many offices now offer early or late hours for patients. Are you interested in positions that start early in the morning?_________ Are you interested in offices that offer late appointments? ______
Are there benefits you are looking for in a position? Please Specify _________________________
_____________________________________________________________________________
What days are you looking for employment? _________________________________________
Are you flexible on the days? _______ Are you looking for Part-time or Full-time? _____________
When accepting a permanent position through Daily Dental Solutions, inc. it is your express responsibility to inform us immediately if you are released or resign from the said position.
Please send us a current resume via email or send it on flash drive or CD. We reserve the right to verify previous employment & references, as well as, make any needed changes to your resume.
______________________________ _____________________________ ____________
Print Name Signature Date
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