FAMILY DENTAL CARE™ APPLICATION FOR EMPLOYMENT

APPLICATION FOR EMPLOYMENT

PRE-EMPLOYMENT QUESTIONNAIRE - AN EQUAL OPPORTUNITY EMPLOYER
Date

MonthDayYear
Date
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you 18 or older?

YesNo
How did you hear about this job?
Position applying for
What type of employment do you seek?

Full TimePart Time
What Languages do you speak?
Computer Programs familiar with:
Can you legally work in the United States?

YesNo
EDUCATION
HIGH SCHOOL
Name of School
City
City of High School
Did you graduate?
Yes or No
COLLEGE
Name of School
City
City of College
Did you graduate?
Yes or No
OTHER EDUCATION
Name of Other School
City
Enter the City of Other School
Did you graduate?
Yes or No
EXPERIENCE

Most recent or current employer
Company Name & Address
Employment From

MonthDayYear
Date
Employment Until

MonthDayYear
Date
Position & Duties
Reason for Leaving
EXPERIENCE

Prior employment
Company Name & Address
Employment From

MonthDayYear
Date
Employment Until

MonthDayYear
Date
Position & Duties
Reason for Leaving
EXPERIENCE

Additional prior employment, if needed
Company Name & Address
Employment From

MonthDayYear
Date
Employment Until

MonthDayYear
Date
Position & Duties
Reason for Leaving
REFERENCES
Reference #1

First NameLast Name
Phone Number

Area CodePhone Number
Occupation
What do they do for a living?
Relationship to you
Reference #2

First NameLast Name
Phone Number

Area CodePhone Number
Occupation
What do they do for a living?
Relationship to you
PRE-INTERVIEW QUESTIONS FOR JOB APPLICANTS
Applicant's Name:
Your full name, please.
Date

MonthDayYear
Date
A) Do you have any experience working in a dental office?
B) Why would you like to work in a dental office?
C) Given a choice, what position would you like to work in our office? Please select.

Clinician (Dental Assistant)Front Desk/ReceptionInsurance DepartmentOther
D) How far is our office from your house?
Approximate mileage
E) Is transport to our office a problem?
F) We require full-time employees to work two nights per week (8:00pm) and two Saturdays per month. Can you fulfill these hours?

YesNo
G) Do you have any obligations that would prevent you from being on time to work?
H) What range of salary (hourly rate) do you expect to get in this job?
I) What problems or situations are/were you experiencing at your present job that you wish are different at your new job?
I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT. I FURTHER AUTHORIZE AND CONSENT TO A BACKGROUND CHECK AT ANY TIME PRIOR TO OR DURING MY EMPLOYMENT, IF EMPLOYED.
Signature

Clear
Date Signed

MonthDayYear
Date
FOR OFFICE USE ONLY
Staff Members Name:
For Office Use Only
THIS APPLICATION, IN ITS ENTIRETY, WILL BE SUBMITTED ELECTRONICALLY

Copyright © 2014 Alex Alemis, D.D.S. All Rights Reserved
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APPLICATION FOR EMPLOYMENT

EDUCATION

EXPERIENCE

EXPERIENCE

EXPERIENCE

REFERENCES

PRE-INTERVIEW QUESTIONS FOR JOB APPLICANTS

FOR OFFICE USE ONLY