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Doctors Staffing and Resources, Inc.,
Crescent Square Office Park
11075 South State #4
Sandy, UT 84070

Office (801) 576-0335
Fax (801) 576-1361
Request to Temp
Complete the following information and click the Send button (at the bottom of the page). Required fields are indicated with an asterisk.
*Name
*E-mail
*Daytime telephone
Other telephone
Address
City / State / ZIP
*Social Security Number
  We must have your SSN to employ you.
Hygiene License #
Is your license current? Yes
No
Where are you currently employed?
What is your current pay rate?
  Temporary employee rates: $10.00 an hour for Dental Assistants; $28.00 an hour for Hygienists
Are you available for temping? Yes
No
Which days you are available? Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Any Additional comments
I agree that the above information is true and correct. I also agree when working through Doctors Staffing and Resources, Inc. (DSR), I will report any additional days worked for any doctor. Failure to do this will preclude DSR from using me in the future and will also carry a fine. Further, I recognize that it is also my responsibility to report permanent positions that have been offered to me. I also understand that personnel provided by DSR shall be employees of the doctor and not of DSR.
Yes No