Substitute List Form

Isaac Knapp District Dental Society Sub List

Please fill out the information below to be placed on our sub list. Your information will remain on the list for 1 year, unless you notify the IKDDS office to update. You must re-submit your information annually to ensure that the most recent information is distributed to dental offices.
Name*

First Name Last Name
Phone Number*

Area Code Phone Number
E-mail*
Position you are qualified to sub for:

HygienistDental AssistantOffice AssistantLab Tech
Are you x-ray certified?
Are you expanded duties?
What days are you available to sub?

MondayTuesdayWednesdayThursdayFridaySaturday
Are you interested with long-term sub opportunities?
Example: to fill for someone on maternity leave
Additional comments
Contact information will be kept for sub list distribution to IKDDS Members for 1 year. I will need to re-submit information annually.*

Yes, I understand IKDDS will keep my information for 1 year.
Should be Empty:

Isaac Knapp District Dental Society Sub List