Application Form

Personal Information

Name(Required)

First Last

Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you lived in this area?

Social Security Number(Required)

How did you hear about this position?

Phone(Required)

Email(Required)

Please indicate position(s) applying for

Interest in(Required)

Transportation to work(Required)

Experience and Skills

Typing (wpm)(Required)

Tray Setup(Required)

Sales(Required)

Chairside Assisting(Required)

Management/HR(Required)

Taking BWX/PA X-rays(Required)

Marketing(Required)

Taking Pano/FM X-rays(Required)

Treatment Presentation(Required)

Taking Intra-oral Photos(Required)

Dental Insurance(Required)

Coronal Polish(Required)

Dental Terminology(Required)

Fabricate Temp Crowns(Required)

Claims Processing(Required)

Use of Cerec Machine(Required)

Appointment Scheduling(Required)

Zoom(Required)

Account Collections(Required)

Taking Impressions(Required)

Accounts Payable(Required)

Pour/Trim Models(Required)

Maintenance of Recall(Required)

Sedation Dentistry(Required)

Dentrix Software(Required)

Assisting ORAL SURGERY(Required)

Computer(Required)

Date Earned Certificate or License for:

X-RAY

RDA

EDDA

RDH

RDH/EF

CPR

ACLS

General Information

Are you at least 18 years old? (If no, please provide work permit)

Yes

Do you have the legal right to work in the U.S.? (proof will be required upon employment)

Yes

Can you fulfill the job duties and responsibilities of this position as they have been described?

Yes

Are you available to stay after scheduled office hours last minute to accommodate patients?

Yes

If applicable, do you have the required license(s) to perform the job? (please provide copies)

Yes

Have you completed all Hepatitis vaccination requirements?

Yes

Can your vacations be arranged at practice convenience? If not, please explain.

Yes

Do you use illegal drugs?

Yes

Have you ever been convicted of a crime other than a traffic violation? If yes, please explain.

Yes

Date available to start?(Required)

What is your expected length of employment?

Salary requirements per hour

Salary requirements per hour after one year

Salary requirements per hour after two years

Benefit requirements

Hobbies and interests/favorite recreation

Work Experience

Answer all questions here and throughout this employment application. Do not substitute with resume. List present or most recent position first. Attach additional pages if needed. Please account for time not employed.

Employer One

Name of employer

Phone

Address

Start Date

End Date

Position Held

Supervisor’s Name and Title

Average # of hours worked per week

Your last name at time of employment

Starting Rate of Pay

Ending Rate of Pay

Describe your duties

Give specific reason(s) for leaving

May we contact this employer?

Yes

If no, explain

Employer Two

Name of employer

Phone

Address

Start Date

End Date

Position Held

Supervisor’s Name and Title

Average # of hours worked per week

Your last name at time of employment

Starting Rate of Pay

Ending Rate of Pay

Describe your duties

Give specific reason(s) for leaving

May we contact this employer?

Yes

If no, explain

Employer Three

Name of employer

Phone

Address

Start Date

End Date

Position Held

Supervisor’s Name and Title

Average # of hours worked per week

Your last name at time of employment

Starting Rate of Pay

Ending Rate of Pay

Describe your duties

Give specific reason(s) for leaving

May we contact this employer?

Yes

If no, explain

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

PLEASE READ THE FOLLOWING AND SIGN BELOW

GENERAL AGREEMENT

If hired, I will provide legal proof of identity and authority to work in the United States. I agree to conform to the rules and standards of the practice, as amended from time to time at the employer’s discretion. I understand that any misrepresentation, falsification, or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, in my dismissal from employment. I hereby certify that the information contained in this application form is true and correct to the best of my knowledge.

EMPLOYMENT RELATIONSHIP

If hired, I understand that employment with the practice is not for a specified term and can be terminated “At Will”, with or without cause, and with or without notice, at any time, either at the option of the employee or the employer. No employee or representative of the practice, other than its owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the employer may not alter the “At Will” nature of the employment relationship unless it is done specifically in writing and is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the “At Will” nature of my employment relationship. There are no oral or collateral agreements regarding this issue.

AUTHORIZATION TO CHECK REFERENCES/ BACKGROUND CHECK/ DRUG TEST

All offers of employment are conditioned on receipt of satisfactory responses to reference requests, official background check, and drug test. Unless I have otherwise indicated above, I authorize the references listed, as well as all other individuals whom the practice may contact, to provide any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties from all liability of any damages that may result for furnishing the practice with such information as well as from the use or disclosure of such information by the employer or any of its agents, employees or representatives.

About Us

Locations

Application Form

Personal Information

Experience and Skills

Education

Highschool

College

Post Graduate

DA School

Hygiene School

Certificates or Licenses

Date Earned Certificate or License for:

General Information

Work Experience

Employer One

Employer Two

Employer Three

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

PLEASE READ THE FOLLOWING AND SIGN BELOW

GENERAL AGREEMENT

EMPLOYMENT RELATIONSHIP

AUTHORIZATION TO CHECK REFERENCES/ BACKGROUND CHECK/ DRUG TEST