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Dental Hygiene Department Dental Work Experience Verification Form Complete one form per employer to document up to 3200 hours. Applicant Name Date The above named applicant has worked/volunteered circle one in this dental office/clinic for Years Months Weeks Average number of hours each week 32 - 40 hours/week full time 50 weeks 1 year Total hours worked Please do not enter hours per week. Name of office or clinic Employer s Signature Date I certify that I am the person identified and the above information is accurate. Applicant Attestation Signature Brief explanation of dental assisting training List specific duties List skills in which you feel competent performing as a dental assistant Yakima Valley Community College does not discriminate against any person on the basis of race color national origin disability sex genetic information or age in admission treatment or participation in its programs services and activities or in employment. All inquiries regarding compliance should be directed to the Director of Human Resource Services YVCC South 16th Ave. Applicant Name Date The above named applicant has worked/volunteered circle one in this dental office/clinic for Years Months Weeks Average number of hours each week 32 - 40 hours/week full time 50 weeks 1 year Total hours worked Please do not enter hours per week. Name of office or clinic Employer s Signature Date I certify that I am the person identified and the above information is accurate. Name of office or clinic Employer s Signature Date I certify that I am the person identified and the above information is accurate. Applicant Attestation Signature Brief explanation of dental assisting training List specific duties List skills in which you feel competent performing as a dental assistant Yakima Valley Community College does not discriminate against any person on the basis of race color national origin disability sex genetic information or age in admission treatment or participation in its programs services and activities or in employment. Applicant Attestation Signature Brief explanation of dental assisting training List specific duties List skills in which you feel competent performing as a dental assistant Yakima Valley Community College does not discriminate against any person on the basis of race color national origin disability sex genetic information or age in admission treatment or participation in its programs services and activities or in employment. All inquiries regarding compliance should be directed to the Director of Human Resource Services YVCC South 16th Ave. Applicant Name Date The above named applicant has worked/volunteered circle one in this dental office/clinic for Years Months Weeks Average number of hours each week 32 - 40 hours/week full time 50 weeks 1 year Total hours worked Please do not enter hours per week. Name of office or clinic Employer s Signature Date I certify that I am the person identified and the above information is accurate. Applicant Attestation Signature Brief explanation of dental assisting training List specific duties List skills in which you feel competent performing as a dental assistant Yakima Valley Community College does not discriminate against any person on the basis of race color national origin disability sex genetic information or age in admission treatment or participation in its programs services and activities or in employment.

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Keywords relevant to Experience Verification Form

  • blvd
  • Applicant
  • discriminate
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