Teacher Application

	Note: Enter "N/A" for any information that is not applicable to you.
* Today's Date:

	*Applicant's General Information:*
* Name:
* Date of Birth:	/ /
* Street Address:

* City:
* State:
* Zip:
* Phone:
* Mobile Phone:
* Email Address:
* Best Time To Call:
* How Long Have You Been A Dental Assistant or Teacher? :

	Dental Experience: List dates and duties starting with the most recent. Example: Jan 2004 to April 2006 -- Dr. Jim Smith -- X-rays, impressions, etc.
* Chairside:
* Business Office/Office Manager:
* Expanded Duties Dental Assistant/ Place Amalgams & Composites & Make Temporaries:
* Lab:
* Orthodontic Assistant:

	Teaching Experience: LIst teaching experience in any capacity.
* Dental Office:
* Dental Assisting School:
* Public or Private School:
* Church:
* Any Degrees:

	Training Experience: List training as a dental assistant you have completed.
* Dental Assisting School:
* CE Courses:
* On The Job Training:
* CDA Certificate:
* CDA Certificate Is Up To Date?:

	Past Employment: List the last 3 places of dental office employment and the reason for changing positions.
* First:
* Second:
* Third:

	*References & Short Questionare:*
* Workplace Reference(s) With Phone Number:
* Why Would You Like To Teach Dental Assisting?:

	Available Work Hours: Check any that apply.
	Full Time
	Part Time
	Day
	Evening
	Saturday

* Select Location: