RICCOBENE ASSOCIATES - TEMP/Working Interview FORM

RICCOBENE ASSOCIATES FAMILY DENTISTRY

Thank you for working at Riccobene Associates FamilyDentistry! Please complete the basic questions below so we can add you to our HR/Payroll system. Also, please submit your timecards directly to temps@brushandfloss.com to confirm your hours worked.
Temp Form - W2 employee (payroll/HR)

Please complete this form to ensure we add you to our HR/payroll system [Paycom]. You will be receiving an email directly from Paycom with your employee self-service login and password. Please complete the 'temp checklist' to ensure you get paid properly. In the checklist you will need to complete tax forms, direct deposit forms, form I9, etc. In addition, you will be able to go under 'time management' and submit your hours directly.
Please keep an eye out for your employee self-service login from PAYCOM to complete 'TEMP CHECKLIST' which MUST be completed before payroll is processed. Please also bring copy of 2 forms of identification for employment verification (ex: driver's license and social security card OR passport).

temps@brushandfloss.com
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Hire Date/Date started working*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Social Security # (XXX-XX-XXXX)*
Upload copy of Driver's license

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Please upload 2 forms of identification for Form I-9 verification (ex: social security card & Driver's license) OR 1 form of identification (passport)

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Gender*
Position*
Are you a Temp or doing working interview?*

TempWorking InterviewMarketing canvasser/help
Office Location (which office are you working in?)*
Office Location*
Hourly Rate ($)?*
Which temp agency referred you? (answer question if applicable)
OSHA/Bloodborne pathogen training required prior to coming onsite:
What is your T-Shirt size?
Signature*

Please click SUBMIT button below. Also, keep in mind you can enter your hours directly in the system under 'time management', 'web time clock' upon completion of your shift at the office.

If Temp Dentist please complete section below:

If you are a temp dentist, temp hygienist, these are items that are needed prior to you working for compliance purposes. Please bring copy of License to practice.
NC Dental License #*
Provide copy of NC Dental license (you can take copy from smart phone and upload below):

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NPI #*
If do not have one or know it, please say N/A
DEA # (if applicable)*
If do not have one or know it, please say N/A
Provide copy of Individual malpractice insurance (you can take copy from smart phone and upload below):*

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This is needed prior to starting; you can provide to office manager. Cancelof

If Temp Dental Hygienist please complete section below:

If you are a temp dentist, temp hygienist, these are items that are needed prior to you working for compliance purposes. Please bring copy of your hygiene license for display.
Dental Hygienist License #
Please upload Dental Hygienist License (upload from smart phone)

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Please upload copy of immunization records

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If Temp Dental Assistant please complete section below:

If you are a temp dentist, temp hygienist, these are items that are needed prior to you working for compliance purposes.
Did you graduate from an accredited Dental Assistant Program (ex: Wake Tech, etc.- this is where your diploma includes your X-ray, coronal polishing certifications & you are a DA2)
If 'yes'....Please provide copy of diploma from accredited DA program (you can use smart phone to upload picture)

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If 'no'....please provide copy of x-ray certification

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If 'no'....please provide copy of coronal polishing certification (if applicable)

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If 'no'....please provide copy of nitrous certification (if applicable)

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Please upload copy of immunization records

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Signature

Clear
Should be Empty:

RICCOBENE ASSOCIATES FAMILY DENTISTRY

Temp Form - W2 employee (payroll/HR)

If Temp Dentist please complete section below:

If Temp Dental Hygienist please complete section below:

If Temp Dental Assistant please complete section below: