Candidate Registration: MDC Staffing LLC, Shiftboard

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* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
I am a:
Chairside Assistant
Front Desk Administrator
Dentist
Registered Dental Assistant
Office Manager
Registered Dental Hygienist
* Educational Level
* Years of Experience
Months of Experience
Experience Start Date
Experience End Date
What days are you available?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Have you had any experience in the following specialty fields?
Perio
Endo
Oral Surgery
Pedo
Ortho
Prostho
Are you interested in a Permanent Position?
Are you interested in a Temporary Position?
Dental License State
Dental License ID
License Expiration
Please tell us your hourly rate:
Do you take digital x rays?
 Yes  No
Which Dental software are you familiar with?
Are you Nitrous Oxide Certified?
 Yes  No
Are you Laser Certified?
 Yes  No
Are you Sealant Certified?
 Yes  No
Are you Coronal Polishing Certified?
 Yes  No
How were you referred to MDC staffing?
Are you Bilingual?
 Yes  No
What Languages?
Level 1 Sedation Permit
 Yes  No
Jurisprudence Assessment for Licensure renewal
 Yes  No
Completion Date

Background Check Information
* Do you consent to a background check?
 Yes  No
* Felony Convictions
 Yes  No
* Drivers Licence Number
* Drivers License State
Social Security Number
Birthdate
If you have your CPR license, what is the expiration date?
If you are current in HIV and Blood borne pathogens, what is the date of certification?
If you have a current Hippa certification what is the date of certification?
Have you had Hepatitis B Vaccine?
 Yes  No
I have been advised of the benefits of the Hepatitis B Vaccination but I am declining the vaccination at this time. If so, complete date below.



We appreciate your time and interest


 
 
Cypress, Texas 77429
281-758-1999
Shiftboard® is a registered Trademark of Shiftboard, Inc.
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