Placement Request Form

Today’s date: ________

Dr. ______________________ Florida license # _______________________

Office address: __________________________________________________

Business phone: ______________ Fax #: _____________ Email address: ____________

Position needed: _____ Registered dental hygienist _____ Receptionist

_____ Dental assistant, CDA required or not? _____

_____ Office manager _____ Sterilization technician

I am in need of a temporary personnel _____ or permanent personnel _____

Date(s) of needed staff: _____________________________________________

Wages $_____ per day or $_____ per hour

Contact person: _______________________________

What type of practice do you have? (general, perio, etc) __________________

Office Hour: _____________________________________________________

Comments: ______________________________________________________

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