Please enable JavaScript in your browser to complete this form.Click HERE to go back to staff availability.NameClick Dates to View on CalendarClick HERE to go back to staff availability. Phone NumberEmail AddressStreet AddressJob *HygienistFront OfficeAssistantUpload Your Resume Click or drag a file to this area to upload. Expected Hourly RateDo you speak a 2nd language?Hygiene License Expiration DateHygiene License NumberAre you CPR Certified? *YesNoCPR Expiration DateUpload a Picture of Your CPR Card Click or drag a file to this area to upload. Are you Nitrous Oxide Certified?YesNoUpload your Nitrous Oxide Certification Click or drag a file to this area to upload. Are you Local Anesthesia Certified? *YesNoUpload your Local Anesthesia Certification Click or drag a file to this area to upload. Are you Laser Certified *YesNoUpload your Laser Certification Click or drag a file to this area to upload. Are you familiar with Eaglesoft Dental Practice Management Software *YesNoAre you familiar with Dentrix Dental Practice Management Software *YesNoAre you familiar with SoftDent Dental Practice Management Software *YesNoAre you familiar with PracticeWorks Dental Practice Management Software *YesNoAre you familiar using other Cloud Applications *YesNoPlease list the other Cloud Applications you have usedAre you Expanded Duties Skills for Dental Assistants (EDDA) Certified *YesNoUpload your EDDA Certification Click or drag a file to this area to upload. Are you X-Ray Certified *YesNoUpload your X-Ray Certification Click or drag a file to this area to upload. Years of ExperienceChairside ExperienceOrtho - Experience with BracketsEDDA ExperienceOrtho - Experience with InvisilineOral Surgery ExperiencePedo ExperienceEndo ExperienceExperience with Universal Sterilization *YesNoExperience with Coronal Polishing *YesNoExperience with Temporary Crowns *YesNoExperience with Four Handed Assisting *YesNoExperience with Alginate Impression *YesNoExperience with Composites *YesNoExperience with Cord Packing *YesNoExperience with Denture Adjustments *YesNoExperience with Amalgams *YesNoExperience with Final Impressions *YesNoExperience with Rubber Dams *YesNoUpload Driver's License Click or drag a file to this area to upload. Upload Social Security Card Click or drag a file to this area to upload. Signature *Clear SignaturePlease sign to certify your answers are true and complete