Dental Assisting Program - Employer Request Form

Business Name*

Business Address*

Type of Practice*

Please indicate the type of practice. Check all that apply

Supervising Dentist's Name*

Supervising Dentist's Email Address*

Supervising Dentist's Phone #*

Can you host an unpaid intern?*

If you are interested in hosting an unpaid intern in spring (April - June), please complete and upload an annual "Agreement for FHDA-C.C.D and Dental Assisting Clinical/Office."

Select or enter value

Can you hire an apprentice?*

If you are planning to hire an apprentice, please upload the completed "Agreement to Train Apprentices" form and a job description.

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Comments/Questions

File Upload*

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Date Submitted*

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