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 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

US Military Service

Branch

Rank

Dates of Service

Yes

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

Telephone:

To:

If YES, Contact Name:

Address:

Job Title:

Reason for Leaving:

Responsibilities:

Previous Employer

Dates Employed

May We Contact?

Employer Name:

From:

Yes

Telephone:

To:

If YES, Contact Name:

Address:

Job Title:

Reason for Leaving:

Responsibilities:

Previous Employer

Dates Employed

May We Contact?

Employer Name:

From:

Yes

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

Bookkeeping

Yes

Computers

Yes

Account/Collections

Yes

Tax Presentation

Yes

Fee Presentation

Yes

Dental Terminology

Yes

Insurance Processing

Yes

Scheduling

Yes

Customer Service

Yes

Charting

Yes

Management

Yes

Clinical Skill

Y/N

Skill Level
(Fair/Good/Excellent)

Tray Setup

Yes

Four-handed Dentistry

Yes

Six-handed Dentistry

Yes

Take, Develop, Mount X-rays

Yes

Pour & Trim Models

Yes

Coronal Polish

Yes

Fabricate/Cement Temp Crowns

Yes

OSHA & Safest Regulations

Yes

Plaque Control Instructions

Yes

Periodontal Skills

Yes

Orthodontic Skills

Yes

Oral Surgery Assisting

Yes

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

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