Date

Application Form

The Dental Network
2323 S. Shepherd Suite940 Houston, TX 77019
713.527.8367 or toll free 1.866.813.8367
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Position Desired:               Dentist          Hygienist          Registered Chairside Asst.         Front Desk

Name  S.S.#

Address City State Zip

TX. DL# DOB E-mail

Phone#: Home  WKCell

Institution Attended    Yr. of Graduation

DDS/RDH License#    Years of Chairside Experience?

Available work days?        Available work months?   

Who referred you to T.D.N?        

Check Office Preference:    GP     Pedo     Perio     Endo     OS     Ortho

Software Knowledge: Dentrix Eaglesoft Softdent Doc-Aid Other

Check your Placement Preference:    Temporary           Permanent

Compensation Rate?    Preferred areas of Town?

Have you had your Hepatitis Vaccine?    Yes?        No?

Are you Certified in:  Sealants?Radiographs?Are you Familiar with Digital X-RAYS?

List of expanded duties, Include any continuing education

Last (3) Employers beginning with most recent: Include phone numbers

Have ever been charged or convicted of a felony? Yes No If yes, explain