Form 4 - Work Verification For Lcc Dental Hygiene Program printable pdf download

Name as indicated in myLane

L# ______________________ First _____________________________ Last __________________________________

FORM 4 - Work Verification for LCC Dental Hygiene Program

PURPOSE:

Applicants to the Dental Hygiene program at Lane Community College can gain additional points toward their application

from prior or current employment in a dental office. The application process requires verification of paid work experience

in a dental office. Employers (either Supervisor or Human Resources representative) are asked to verify the applicant’s

description of job duties and number of hours of patient care using this form.

INSTRUCTIONS:

1. Applicant completes Part 1 before sending the form to the employer/agency. Duplicate this form for additional

employers.

2. Employer/agency completes Part 2 and returns form to applicant.

PART 1. To be filled out by Dental Hygiene Applicant

Applicant Name: ________________________________________

Prior Name if applicable: _____________________

Applicant Address: _____________________________________________________

SS#: _____________________

Facility Name and type: _______________________________________________________________________________

Facility Current Address: ______________________________________________________________________________

Length of employment (mm/dd/yy): from __________ to ___________

Total Hours Paid Dental Office work: ________

Job Title: ________________________________________________

Supervisor: _____________________________

Complete a detailed description of Job Duties (any additional pages added must be signed by Dentist or HR)

I allow Lane Community College to verify this information. I acknowledge that any false information I provide is subject to

disciplinary action as stated in the LCC Student Code of Conduct.

Applicant’s Signature: ____________________________________

Date: ________________________

Dear Employer,

Please return the completed form by _______________________ (date to be filled in by applicant) so the

applicant may include the form with the Dental Hygiene Program Application.

PART 2. To be signed by Dentist or Human Resources representative.

Facility Name: _________________________________________

Phone: ___________________________

Supervisor of Applicant (must be a Dentist): ______________________________________________________

I verify the information provided by the applicant to be accurate and true to the best of my

knowledge.

applicant added additional detail to description of job duties, I have signed that addendum also.

Supervisor or Human Resources Representative: __________________________________________________

Title: ________________________________________________

Phone: _____________________________

Signature: _____________________________________________

Date: _____________________________

All information in the shaded area is required. It is the student’s responsibility to be sure that all parts of this form are completed.

Students: If you are unable to obtain the necessary information send questions to DHProgram@lanecc.edu.

1 of 1

2/3/2016

Form 4 - Work Verification For Lcc Dental Hygiene Program

Related Articles

Related forms

Related Categories