Application for Dental Office Employment

List the last 7 years, including periods of self-employment or unemployment. Answer all questions here and throughout this employment application – do not substitute with resume. List present or most recent position first.

PLEASE READ THE FOLLOWING AND SIGN BELOW

GENERAL AGREEMENT
If hired, I will provide legal proof of identity and authority to work in the United States. I agree to conform to the rules and standards of the practice, as amended from time to time at the employer’s discretion. I understand that any misrepresentation, falsification, or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, in my dismissal from employment. I hereby certify that the information contained in this application form is true and correct to the best of my knowledge.

EMPLOYMENT RELATIONSHIP
If hired, I understand that employment with the practice is not for a specified term and can be terminated “At Will”, with or without cause, and with or without notice, at any time, either at the option of the employee or the employer. No employee or representative of the practice, other than its owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the employer may not alter the “At-Will” nature of the employment relationship unless it is done specifically in writing and is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the “At-Will” nature of my employment relationship. There are no oral or collateral agreements regarding this issue.

AUTHORIZATION TO CHECK REFERENCES
All offers of employment are conditioned on receipt of satisfactory responses to reference requests. Unless I have otherwise indicated above, I authorize the references listed, as well as all other individuals whom the practice may contact, to provide any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from all liability for any damages that may result from furnishing the practice with such information as well as from the use or disclosure of such information by the employer or any of its agents, employees, or representatives.

I hereby agree to a background check to be conducted in respect of the information provided in this application, and I hereby waive my right to receive a copy of any record(s) obtained as a result of reference checks.

Application forms will be retained for a period of one year.

Note:This Application for Employment was prepared for general use throughout the United States and in consultation with legal counsel. It is designed to comply with Federal and State Fair Employment Practice Laws. However, since State and local laws vary, Bent Ericksen & Associates assumes no responsibility for the inclusion in this application form of any questions that may violate Federal, State, or local laws.