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Please complete and return to Ifloss Coalition. The information you provide will be used to market your community and practice site; therefore, it is important to be as detailed and thorough as possible. Ifloss Coalition |
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| Name of Practice Site | Name of Administrative Office (if different) | ||||||||||||||||||||
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| Address | Administrative Address | ||||||||||||||||||||
| City, State, Zip | City, State, Zip | ||||||||||||||||||||
| Contact (person responsible for recruitment) | Administrative Contact | ||||||||||||||||||||
| Contact’s Title | Contact’s Title | ||||||||||||||||||||
| Phone | Phone | ||||||||||||||||||||
| Fax | Fax | ||||||||||||||||||||
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| Number of dentists at site: | |||||||||||||||||||||
| Number of dental assistants: | |||||||||||||||||||||
| Number of dental hygienists: | |||||||||||||||||||||
| Number of dental operatories: | |||||||||||||||||||||
| Practice type: | Private Non-Profit Public | ||||||||||||||||||||
| Practice description (check all that apply): | Solo Solo w/Assoc. Single Specialty Group Multi Specialty Group Community Health Center Rural Health Center Migrant Health Center Hospital Based Community Based State Institution/Facility Health Department | ||||||||||||||||||||
| Additional practice details: | |||||||||||||||||||||
| COMMUNITY INFORMATION : | |||||||||||||||||||||
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| HPSA: | Yes No | ||||||||||||||||||||
| NHSC site: | Yes No | ||||||||||||||||||||
| DENTAL OPPORTUNTIES: | |||||||||||||||||||||
| Please indicate the number of opportunities for each specialty and the proposed hire date: | |||||||||||||||||||||
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| ADDITIONAL POSITION DETAILS: | |||||||||||||||||||||
| Language skills preferred of applicants? |
Yes
No Which?: |
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| If so, is this a requirement? | Yes No | ||||||||||||||||||||
| Vacation (# of days/year): | |||||||||||||||||||||
| Salary Range : | |||||||||||||||||||||
