Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Which position are you applying for? * Dental Assistant / EFDA (Full-time) Dental Hygienist (Part-time) Restorative Hygienist (Full-time) Do you have a Registered Dental Assistant (RDA) certification? * Yes No Do you have an EFDA (Expanded Function Dental Assistant) certification? Yes No Do you have a valid Dental Hygienist license in Washington? Yes No Have you graduated from an accredited dental hygiene program? Yes No Please list any other relevant certifications or licenses (e.g., X-Ray certification, local anesthesia, nitrous oxide administration). How many years of experience do you have as a Dental Assistant? None Less than 1 year 1–2 years 3–5 years 5+ years (Minimum 1 year required for Dental Assistant / EFDA) How many years of experience do you have as a Dental Hygienist? None Less than 1 year 1–2 years 3–5 years 5+ years Have you performed restorative procedures (e.g., placing composite or amalgam restorations)? Yes No Are you proficient in using dental software systems? Yes No Do you have experience taking dental X-rays? Yes No Do you have experience educating patients on oral hygiene practices? Yes No Are you comfortable administering local anesthesia or nitrous oxide? Yes No I certify that the information provided in this application is true and accurate to the best of my knowledge. * I agree We have received your Application and will reach out to you. Thank you! Tour Our Office Say Goodnight to Dental Anxiety Book Appointment