Application For Employment Dental

"*" indicates required fields

Name*

First Middle Last

Other Names Used

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Email Address*

QUESTIONS ABOUT APPLICANT

Position Desired*

Date Available*

Type of employment desired*

Full Time

Part Time

Temp/Seasonal

On-Call

What days are you available to work (check all that apply)*

What shifts are you available to work (check all that apply)*

Morning

Afternoon

Evening

Are you legally eligible for employment in the United States?*

Yes

(Proof of U.S. citizenship or immigration status will be required upon employment)

Are you 16 years of age or older*

Yes

Have you applied or worked here before?*

Yes

when?

How did you hear about this position?

EDUCATIONAL BACKGROUND

High School Education or GED passed?*

Yes

Please indicate highest grade completed:*

EDUCATIONAL BACKGROUND

College/University/Trade School

City/State

Units

Degree/Diploma

Major

Completed

US Military Service

Branch

Rank

Dates of Service

EMPLOYMENT HISTORY

List all positions held, including part-time summer and/or volunteer work and periods of employment for the last ten years; do not omit any employers. Explain any gaps in employment in comment section. If you are submitting a resume, you are still required to provide the requested information in the space provided. If self-employed, provide company name and at least two business references. Attach additional sheets or continue on the back of the page, if needed.

Current Employer

Employer Name

Dates Employed From

Dates Employed To

May We Contact?*

Yes

Contact Name

Telephone

Address

Job Title

Reason for Leaving

Responsibilities

Previous Employer

Employer Name

Dates Employed From

Dates Employed To

May We Contact?*

Yes

Contact Name

Telephone

Address

Job Title

Reason for Leaving

Responsibilities

Have another previous employer?

Hidden

Section Break

Previous Employer

Employer Name

Dates Employed From

Dates Employed To

May We Contact?*

Yes

Contact Name

Telephone

Address

License #

Date Earned

State Issued

Current through Date

Hidden

Office Skill

Typing

Bookkeeping

Computers

Account/Collections

Tax Presentation

Fee Presentation

Dental Terminology

Insurance Processing

Scheduling

Customer Service

Charting

Management

Clinical Skill

Tray Setup

Four-handed Dentistry

Six-handed Dentistry

Take, Develop, Mount X-rays

Pour & Trim Models

Coronal Polish

Fabricate/Cement Temp Crowns

OSHA & Safest Regulations

Plaque Control Instructions

Periodontal Skills

Orthodontic Skills

Oral Surgery Assisting

Please list languages spoken fluently, other than English

Please list any additional pertinent skills, special training, certifications or qualifications

Please list any other accomplishments, awards, professional groups of which you are a member, or additional information you would like us to consider

I certify that my answers are true and complete to the best of my knowledge.*

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I further understand that any employment that is offered to me will be at-will and that this application does not create or imply a contract for employment.

Applicant Signature

Date

Contact

Directions

Office Hours

Monday: 10 am – 6pm
Tuesday: 10am – 7pm
Wednesday: 10am –7pm
Thursday: 9am – 6pm
Friday: Closed
Saturday: 9am – 1pm (once monthly)
Sunday: Closed