First name:_ Last name:__

Address:_________________________________________________________

Best contact phone #:________________ Alternate phone #:_____________

Social Security #:______________ Email Address:_________________

I am applying for: (check one)

_____ Registered dental hygienist, Florida license # _______________________

_____ Dental Assistant, CDA ________, Fl certificate for radiographs ________

Expanded function _________

_____ Receptionist

_____ Office Manager

_____ Sterilization technician

I am looking for: _____ temporary _____ permanent position

Days available: _____ Monday _____ Tuesday _____ Wednesday

_____ Thursday _____ Friday _____ Saturday

I am willing to travel to the following cities:

_____ Auburndale _____ Avon Park _____ Bartow _____ Brandon

_____ Clermont _____ Davenport _____ Fort Meade _____ Frostproof _____Haines City_____ Kissimmee _____ Lake Alfred _____ Lakeland

_____ Lake Wales _____ Mulberry _____ Plant City_____ Polk City

_____ Sebring _____ Wauchula _____ Winter Haven _____ Valrico

I have been in the dental field: _____ New graduate _____ 1-3 years _____ 4-6 years

_____ 7-9 years _____ 10 + years

Name of hygiene school or assisting school attended __________________________

The year I graduated __________

The salary range I desire: $________ to $ ________

Comments: _____________________________________________

First name:___________________ Last name:____________________