( -098 91 ) 54 - AdvDentalTemps
REFERRAL TIME SHEET
ADVANCED FACILITY INFORMATION
DENTAL NAME: ADDRESS:
ASSOCIATESINC. PHONE NUMBER:
(919) 545-0985
REFERRAL NAME: ADDRESS:
SS# RATE: DOB:
DATE
START TIME
END TIME
REGULAR HOURS RATE
TOTAL HOURS
WEEKLY TOTALS:
REFERRAL SIGNATURE: SUPERVISOR SIGNATURE :
DATE: DATE:
THE ABOVE FACILITY REALIZES THAT A REFERRAL FEE WILL BE CHARGED BY ADA, INC. WHENEVER THE ABOVE REFERRAL IS EMPLOYED ON A TEMPORARY BASIS FOR THE NEXT TWELVE MONTHS. THE FACILITY ALSO REALIZES THAT IF THEY PERMANENTLY HIRE THE ABOVE REFERRAL THEY WILL BE BILLED A PERMANENT PLACEMENT FEE.
PLEASE MAKE A COPY FOR YOUR OFFICE & HAVE THE TEMPS FAX TO OUR OFFICE Fax: (919) 545 -0123
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