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Dental Hygienist Form
Home
Dental Hygienist Form
Full Name:
Phone Number:
Email Address:
Date of Birth:
Home Address:
Do you have an active NJ Dental Hygiene License?
Yes
No
In progress
License #:
Expiration Date:
Are you certified to administer local anesthesia?
Yes
No
Are you certified in CPR/BLS?
Yes
No
Expiration Date:
Years of Experience as an RDH:
<1
1-2
3-5
5+
Days Available:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Willing to accept:
Same-day/Emergency Shift
Multi-day Temp Assignments
Temp-to-Hire Opportunities
Distance you're willing to travel:
10mi
20mi
30+mi
Preferred Hourly Rate:
Minimum Acceptable Rate:
Please submit the following with this form: if unavailable at this time, they may be submitted at a later date:
Copy of Local Anesthesia Permit (or license number, if applicable):
Copy of CPR Certification:
Photo ID (Driver’s License or State ID):
I confirm that the information above is true and complete to the best of my knowledge.
Signature:
Date
Send
