Application for Employment

We are an equal opportunity employer and do not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability, or any other reason prohibited under Federal, State, or local laws.

Please type or print. This application must be legible, fully completed, signed and dated for consideration.


  • APPLICANT CONTACT INFORMATION
  • Last Name:
  • First Name:
  • Middle Initial:
  • Other Names Used:
  • Street:
  • City:
  • State:
  • Zip Code:
  • Home Phone:
  • Cell Phone:
  • Email Address:

QUESTIONS ABOUT APPLICANT

  • Position Desired:
  • Salary/Wage 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):
  • Sun Mon Tues Wed Thurs Fri Sat
  • 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 No
  • (Proof of U.S. citizenship or immigration status will be required upon employment)
  • Are you 16 years of age or older:
  • Yes No
  • Have you applied or worked here before?
  • Yes No
  • If yes, when?
  • How did you hear about this position?

EDUCATIONAL BACKGROUND

  • High School Education or GED passed?
  • Yes No
  • If NO, please indicate highest grade completed:
  • 8 9 10 11 12
College/University/Trade School City/State Units Degree/Diploma Major Completed
Yes No
Yes No
US Military Service Branch Rank Dates of Service
Yes No
 
  • 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 Dates Employed May We Contact?
Employer Name: From:
Yes No
Telephone: To: If YES, Contact Name:
Address:
Job Title:
Reason for Leaving:
Responsibilities:
Previous Employer Dates Employed May We Contact?
Employer Name: From:
Yes No
Telephone: To: If YES, Contact Name:
Address:
Job Title:
Reason for Leaving:
Responsibilities:
Previous Employer Dates Employed May We Contact?
Employer Name: From:
Yes No
Telephone: To: If YES, Contact Name:
Address:
Job Title:
Reason for Leaving:
Responsibilities:
 
  • SPECIAL TRAINING AND SKILLS
Dental Licenses & Certifications License # Date Earned State Issued Current through Date
X-Ray
CDA
EDDA
RDH
CPR
HIPAA
Other
Office Skill Y/N Skill Level
(Fair/Good/Excellent)
Typing
Yes No
Bookkeeping
Yes No
Computers
Yes No
Account/Collections
Yes No
Tax Presentation
Yes No
Fee Presentation
Yes No
Dental Terminology
Yes No
Insurance Processing
Yes No
Scheduling
Yes No
Customer Service
Yes No
Charting
Yes No
Management
Yes No
Clinical Skill Y/N Skill Level
(Fair/Good/Excellent)
Tray Setup
Yes No
Four-handed Dentistry
Yes No
Six-handed Dentistry
Yes No
Take, Develop, Mount X-rays
Yes No
Pour & Trim Models
Yes No
Coronal Polish
Yes No
Fabricate/Cement Temp Crowns
Yes No
OSHA & Safest Regulations
Yes No
Plaque Control Instructions
Yes No
Periodontal Skills
Yes No
Orthodontic Skills
Yes No
Oral Surgery Assisting
Yes No

 

  • 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.
  • 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
 
 


 

Non-Discrimination Notice   Accessibility Statement

Oak Park Dentist • Family Dental Care of Oak Park • 6943 W. North Avenue, Oak Park, IL 60302 • 708-406-9984

© 2026 DentalWebsites.com (Advanced Web Systems LLC), All rights reserved.