Manual Candidate Complete Registration Form

Full Name
Address 1
Address 2
City
State
Post Code
Mobile Phone
Email
Positions you are a Candidate for?
NPI (Dentist Only)
Years of Experience
Types of offices you have previously worked in?
List Software you are trained/comfortable on:
Are you Bilingual?
If yes, what languages?
Days Available to work (check all that apply)
Areas of town willing to work (check all that apply)
Do you give us consent to contact you via phone, text, and email?
Are you a U.S. Citizen or approved to work in the United States?
Have you ever been convicted of a Felony?
Do you consent to a background check?
Do you confirm that you are in good standings with the dental board?
Do you agree to maintain your state license and all required federal & state requirements?
Are you current in HIV, Blood borne pathogens & COVID?
Have you had your annual HIPAA & OSHA updates?
Have you had your Hepatitis B vaccine?
Dental License Number (Dentist/Hygienist/Assistant)
Dental License Expiration Date (Dentist/Hygienist/Assistant)
CPR Expiration Date
Date Of Birth
Social Security Card
File Upload 1
Drivers License/ID Card
File Upload 2
Resume
File Upload 3
By signing below, you are confirming that all information given is accurate.
Signature 1

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