Form 4 - Work Verification For Lcc Dental Hygiene Program


Name as indicated in myLane
L# ______________________ First _____________________________ Last __________________________________
FORM 4 - Work Verification for LCC Dental Hygiene Program
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.
1. Applicant completes Part 1 before sending the form to the employer/agency. Duplicate this form for additional
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
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
1 of 1


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal