Request to be an Internship Site

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Dentist first and last name*

Practice/clinic name*

Contact person*

Email address*

Phone number*

City of location*

Address

Hours open

Type of practice (pediatric, endodontic, etc.)*

Posting date

Brief description of internship:*

Instructions to apply (include contact information): *

Is an RDA currently employed and able to train the intern?

Yes

No

Will you have full staffing during the internship period?

Yes

No

Are you willing to allow Hancock instructors to observe interns at your office?

Yes

No

Additional comments:

Form UUID Site Name Submit  Clear