SHARK DENTAL ACADEMY

GRADUATING DENTAL ASSISTANT REQUEST FORM

NAME OF YOUR OFFICE *

CONTACT NAME *

PHONE NUMBER( STUDENTS WILL CALL) *

Email(STUDENTS WILL EMAIL ABOUT POSITION) *

ZIP CODE OF THE OFFICE *

X-RAY LICENSE *

COMMENTS

Please note: We will share your contact information with our students. They will come in to your office for unpaid externship and then you may choose to hire them.

WE CAN HELP YOU OPEN A STATE LICENSED DENTAL ASSISTING PROGRAM IN YOUR OFFICE!