Application

EMPLOYMENT APPLICATION
CURRENT POSITIONS:

Hygienist

Indian Trail

Dental Assistant:

Concord, Charlotte, Gastonia, Hickory, or Huntersville

Dentist:

Concord, Charlotte, or Hickory

Patient Relations Coordinator:

Concord

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This application takes approximately 1-5 minutes to complete.
What position are you applying for:
How many years of work experience do you have in this role for which you are applying?*
Desired rate of pay.*
What is the main location you desire to work?*
What locations would you be willing to work?*

ConcordHuntersvilleGastoniaIndian LandHickoryPark RoadCotswoldRemote
Name:*

First NameLast Name
E-mail Address:*
Phone Number*

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number:
###-##-#### or ###.##.####
How did you first hear about this position?*

DentalPostWalk-InEmployeeIndeedFacebookInstagramLinkedInCraigslistFRESHDentalnc.comOther
Please Specify:
Have you worked for FRESHDental before?

YesNo
Please select your experience (select all that apply)

General DentistryPediatric or OrthodonticsPeriodontic or other SpecialtyHealthcare Administrative RoleHealthcare ClinicalBanking or Hotel Front DeskOther
Are you legally able to work in the United States?

YesNo
Have you been convicted of a felony?

YesNo
Please explain the nature of the felony:
Have you ever been fired or asked to resign?*

YesNo
If yes, please explain why:
Please explain any gaps in your employment history within the past 10 years (enter n/a if not applicable):
What is the name of your most recent employer?
Current/Most Recent Employer Phone:

Area CodePhone Number
Are you currently employed?

YesNo
Date Available to Start:

MonthDayYear
Would you like Full-time or Part-time employment?

FTPTTemporary

What is your work availability?

	7:40am - 5pm	7:40am-12:30pm	1pm -5 pm	7:40am - 2:30pm	Not Available
M
T
W
Th
F
S

Upload Resume:

Upload a File

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Job Skills & Training
Highest Education Level Completed:
Major/Concentration:
Name of Institution:
City, State:
Active Certifications/Licenses:*

CPRCDADDSDMDRDHNonePassed DANB ExamCompleted a 1 year CODA accredited programCoronal Polishing CertifiedNitrous-Oxide Oxygen CertifiedOther

Dental Experience

	Beginner	Intermediate	Advanced	Expert	None/N/A
Chair-side Assistang (DA)
Assist Suction
Sterlization
Digital X-rays
Impressions
Anesthesia
Dental Anatomy
Scaling
Probing
Orthodontics
Oral Surgery Procedures
Dental Intelligence
Open Dental
CareStack
Patient Relations

Office Experience

	Beginner	Intermediate	Advanced	Expert	None
Answering Phones
Patient/Customer Relations
Microsoft Outlook
Dental Insurance Verification
Dental Coding
Dental Claims
Billing
Dental Intelligence
CareStack
OpenDental
PowerPoint
Excel
Word
Managing 1-5 employees
Managing 6 or more employees

References

Please list two (2) references that are familiar with your work life.
Reference 1
Name:*

First NameLast Name
This reference:*
Phone Number*

Area CodePhone Number
Email
example@example.com
Years Known:*
Reference 2
Name:*

First NameLast Name
This reference:*
Phone Number*

Area CodePhone Number
Email
example@example.com
Years Known:*
By my e-signature below, I certify that I have given true, accurate and complete information on this form and the attached resume to the best of my knowledge. In the event confirmation is needed in connection with my work, I authorize educational institutions, associations, registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I authorize investigation of all statements made in this application and resume and understand that false information or documentation, or a failure to disclose relevant information may be grounds for rejection of my application, disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon employment shall be mandatory if fraudulent disclosures are given to meet position qualifications.
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EMPLOYMENT APPLICATION