Application Form Personal InformationName(Required) First Last Date(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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)Part TimeFull TimeTransportation to work(Required)Personal vehicleOtherExperience and SkillsTyping (wpm)(Required)NoneFairGoodExcellentTray Setup(Required)NoneFairGoodExcellentSales(Required)NoneFairGoodExcellentChairside Assisting(Required)NoneFairGoodExcellentManagement/HR(Required)NoneFairGoodExcellentTaking BWX/PA X-rays(Required)NoneFairGoodExcellentMarketing(Required)NoneFairGoodExcellentTaking Pano/FM X-rays(Required)NoneFairGoodExcellentTreatment Presentation(Required)NoneFairGoodExcellentTaking Intra-oral Photos(Required)NoneFairGoodExcellentDental Insurance(Required)NoneFairGoodExcellentCoronal Polish(Required)NoneFairGoodExcellentDental Terminology(Required)NoneFairGoodExcellentFabricate Temp Crowns(Required)NoneFairGoodExcellentClaims Processing(Required)NoneFairGoodExcellentUse of Cerec Machine(Required)NoneFairGoodExcellentAppointment Scheduling(Required)NoneFairGoodExcellentZoom(Required)NoneFairGoodExcellentAccount Collections(Required)NoneFairGoodExcellentTaking Impressions(Required)NoneFairGoodExcellentAccounts Payable(Required)NoneFairGoodExcellentPour/Trim Models(Required)NoneFairGoodExcellentMaintenance of Recall(Required)NoneFairGoodExcellentSedation Dentistry(Required)NoneFairGoodExcellentDentrix Software(Required)NoneFairGoodExcellentAssisting ORAL SURGERY(Required)NoneFairGoodExcellentComputer(Required)NoneFairGoodExcellentAssisting ENDO(Required)NoneFairGoodExcellentOSHA & Safety Policies(Required)NoneFairGoodExcellentAssisting IMPLANT(Required)NoneFairGoodExcellentTooth Charting[1-32,A-T](Required)NoneFairGoodExcellentOrtho: 6m smiles/Invis(Required)NoneFairGoodExcellentEducationHighschoolName of Institution Concentration Graduate? Yes No Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY CollegeName of Institution Concentration Graduate? Yes No Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Post GraduateName of Institution Concentration Graduate? Yes No Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY DA SchoolName of Institution Concentration Graduate? Yes No Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Hygiene SchoolName of Institution Concentration Graduate? Yes No Date Started MM slash DD slash YYYY Date Ended MM slash DD slash YYYY Certificates or LicensesDate Earned Certificate or License for:X-RAY MM slash DD slash YYYY DA MM slash DD slash YYYY RDA MM slash DD slash YYYY EDDA MM slash DD slash YYYY RDH MM slash DD slash YYYY RDH/EF MM slash DD slash YYYY CPR MM slash DD slash YYYY ACLS MM slash DD slash YYYY General InformationAre you at least 18 years old? (If no, please provide work permit) Yes No Do you have the legal right to work in the U.S.? (proof will be required upon employment) Yes No Can you fulfill the job duties and responsibilities of this position as they have been described? Yes No Are you available to stay after scheduled office hours last minute to accommodate patients? Yes No If applicable, do you have the required license(s) to perform the job? (please provide copies) Yes No Have you completed all Hepatitis vaccination requirements? Yes No Can your vacations be arranged at practice convenience? If not, please explain. Yes No Do you use illegal drugs? Yes No Have you ever been convicted of a crime other than a traffic violation? If yes, please explain. Yes No Date available to start?(Required) MM slash DD slash YYYY What is your expected length of employment? Salary requirements per hourSalary requirements per hour after one yearSalary requirements per hour after two yearsBenefit requirements Hobbies and interests/favorite recreationWork ExperienceAnswer 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 OneName of employer PhoneAddress Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Position Held Supervisor’s Name and Title Average # of hours worked per weekYour last name at time of employment Starting Rate of Pay Ending Rate of Pay Describe your dutiesGive specific reason(s) for leaving May we contact this employer? Yes No If no, explain Employer TwoName of employer PhoneAddress Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Position Held Supervisor’s Name and Title Average # of hours worked per weekYour last name at time of employment Starting Rate of Pay Ending Rate of Pay Describe your dutiesGive specific reason(s) for leaving May we contact this employer? Yes No If no, explain Employer ThreeName of employer PhoneAddress Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Position Held Supervisor’s Name and Title Average # of hours worked per weekYour last name at time of employment Starting Rate of Pay Ending Rate of Pay Describe your dutiesGive specific reason(s) for leaving May we contact this employer? Yes No If no, explain WE ARE AN EQUAL OPPORTUNITY EMPLOYERPLEASE 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.Consent(Required) I agreeI hereby waive my right to receive a copy of any public record(s) obtained from checking references.