DFI
Please complete the attached information and return to us, along with a copy of your driver's
license, social security card and certifications. Please mail or fax us the information as
soon as possible. Don't hesitate to call with any questions.
Date:_____________
Name:
Work Phone:
Address:
Home Phone:
City State Zip:
Cell Phone:
SS#:
E-mail:
Whom can we thank for referring you to us?
Qualifications:
Assistant/Front Office
Years of Experience:
X-ray License#
Type of Dental Software:
Digital X-ray EFDA EFODA Endo IV Sedation
Oral Surgery Ortho Pedo
Perio Sealant
Hygienist
OR Lic#
WA Lic#
Digital X-ray
Pedo
Type of Dental Software:
Exp. Date
Exp. Date
Perio Local
Years of Experience:
Nitrous
Dentist
DDS/DMD License#
Malpractice Carrier and Policy#:
Years of Experience:
__
Exp. Date
Restorative
Sealant
Employment History: Beginning with your most recent
Name of Employer
Mo/YR-Mo/YR
Position
Telephone
Supervisor
Salary
_____
Education;
College/Technical school:
Date Graduated:
Degree Earned:
Certificate Associates
Bachelors Masters Doctorate
Availability:
Days:
Mon
Thur
Areas:
Flexible
Coast
Tue
Fri
Wed
Sat
Portland Downtown East Side West Side
Eugene/Corvallis Salem/Albany
Washington
Interested in:
Temporary Placement only
Permanent placement only
Either Temporary or permanent
Transportation:
Automobile
Public Transportation
Foreign Languages Spoken:
Are you:
Right Handed
Left Handed
Do you have any work related allergies?
Both Right Handed and Left Handed
YES NO
If yes, please explain:
_
Tuberculosis
I understand that due to my occupational exposure, I may be at risk of exposure to Tuberculosis. I am aware
That OHSU recommends annual TB skin tests.
Intial__________
Hepatitis B vaccine
; I have been previously vaccinated with the hepatitis B vaccine series.
; I have not received the hepatitis B vaccine series.
; I decline the hepatitis B series for temporary employment.
I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at
risk of acquiring Hepatitis B virus (HBV) infection. I have been educated by Dental Fill-Ins, NW LLC about the
importance of having the vaccination, but have declined to receive it at this time. I understand that by declining
this vaccine I continue to be at risk of acquiring Hepatitis B which is a serious disease.
Initial _________
Policy on Drug and Alcohol
Dental Fill-Ins NW LLC prohibits possession, use, dispensation, sale, purchase, manufacture or transportation
of drugs and alcohol. Similarly, reporting to work, working, or while engaged in company activities while under
the influence of drug or alcohol is prohibited. Employees violating this policy may be subject to immediate
dismissal. Some temporary assignments may require a drug screening test or random testing for reasonable
suspicion. We reserve the right to determine whether reasonable suspicion exists.
Initial _________
Availability
It is my responsibility to notify Dental Fill-Ins NW LLC if I am offered additional temporary days or a permanent
position. I will not be employed for a period of 12 months from the last day of my temporary assignment without
notifying DFI so the appropriate fee can be accessed. If you are referred to another dental office while on
temporary assignment or working interview, please inform Dental Fill-Ins NW LLC.
Initial _________
Pay
Wages are set by Dental Fill-Ins NW LLC for all temporary positions. You will be paid by the dental office at the
end of the assignment or on their next regular payroll date. The dental office is responsible for the appropriate
tax withholdings. If you are to be paid as an employee of Dental Fill-Ins NW LLC please note that the pay period
ends every Saturday of the week. You will then receive a pay check the following Friday. In order to be paid we
must have your signed time slips.
Acknowledgment and Declaration
This is a continuing agreement and shall be valid for as long as you are affiliated with Dental Fill-Ins NW LLC. I
accept the terms and conditions of this agreement and acknowledge that I have received a copy.
I declare the information provided by me in this application is true, correct and complete to the best of my
knowledge.
Signature:
Date:
____