Role & Eligibility

Select Position Applied For *

Other *

Do you currently hold an active license required for this role? *

Yes

No

Choose the option NO if you don't require a license

License Type *

License State *

License Number *

Expiration Date *

License, Certification, ID {Passport, Driver's License) *

To be eligible, you must hold or be willing to obtain a license to practice in DC, Maryland, or Virginia.

Yes, I am willing and able to obtain a license.

Personal Information

First Name *

Last Name *

Email *

Mobile Phone *

Street Address *

City *

State *

Country *

Postal code *

Date of birth *

Emergency Contact:

Name

Phone

Relationship

Availability & Preferences

Type of Work Desired *

Contract

Contract-to-Hire

Permanent

Per Diem

Desired Start Date *

Preferred Work Schedule *

Full-Time

Part-Time

Weekends

Flexible

Locations Willing to Work *

DC

Maryland

Virginia

Other

Open to Travel/Float Assignments? *

Yes

No

Credential & Skills Pre-Screening

DDS/DMD License Verification *

Yes

No

Sedation Credentialing *

Yes

No

CPR/BLS Certified *

Yes

No

RDH License Verification *

Yes

No

Local Anesthesia Certification *

Yes

No

Dental Hygienist CPR/BLS Certified *

Yes

No

Radiography Certification *

Yes

No

Sealant Certification *

Yes

No

Dental Assistant CPR/BLS Certified *

Yes

No

Years of Dental Experience *

Practice Type *

Private

DSO

Both

Are You Bilingual?

Yes

No

Languages *

Compliance Disclosures

Are you legally authorized to work in the U.S.? *

Yes

No

Have you ever been excluded from federal programs (OIG/SAM)? *

Yes

No

Consent to Criminal Background Check *

Yes

No

Consent to Drug Screening *

Yes

No

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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