Employer Enrollment Form Please take a moment to fill out the information below completely. Once you complete the form, clock on the submit button to send your application. Someone will contact you within 1 – 2 business days to finalize your submission. If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required Company Information First Name * Last Name * Office Name Address 1 * Address 2 City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip / Post Code * Type of Practice General Oral Surgeon Prosthodonist Periodontist Orthodontist Endodontist Other Email * Office Phone * Alt Phone Cell Phone Contact Person Employment Information Employee Needed * Dental Assistant RDH Office Manager Receptionist Other Type of Work * TemporaryPermanentFull TimePart Time Days Needed MondayTuesdayWednesdayThursdayFridaySaturdaySunday Comments Check if this application is Confidential. The above information will be held strictly confidential. We look forward to having the opportunity to help you with your employment needs.