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