Dental Assistant Application Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred Method of Contact

Phone

Email

Text

Do you have prior experience as a Dental Assistant?

Yes

No

Years of Experience as a Dental Assistant *

Less than 1 year

1-3 years

4-7 years

8+ years

Are you X-ray certified in Tennessee?

Yes

No

CPR Certification:

Current

Expired

Not Yet Certified

What type of employment are you seeking?

Full-Time

Part-Time

When are you available to start?

MM

DD

YYYY