APPLICANT FOR EMPLOYMENT
PREMIER SMILES ORTHODONTICS, GROWING SMILES CHILDREN'S DENTISTRY, INNOVATIVE SMILES & VIP DENTAL ASSISTING SCHOOL ARE AN EQUAL OPPORTUNITY EMPLOYERS
APPLICANT INFORMATION
APPLICATION DATE
*
-
Month
-
Day
Year
Date
FIRST NAME
*
MIDDLE NAME
LAST NAME
*
HOW DID YOU HEAR ABOUT THIS POSITION?
HOW DID YOU HEAR ABOUT US?
*
Please Select
LinkedIn
Indeed
Website
Facebook
Instagram
Flyer in office
Employee
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER
*
PLEASE ENTER A VALID PHONE NUMBER
EMAIL
*
example@example.com
ARE YOU AUTHORIZED TO WORK IN THE U.S.
*
YES
NO
ARE YOU CURRENTLY EMPLOYED?
*
YES
NO
IF YES, MAY WE INQUIRE OF YOUR PRESENT EMPLOYER?
*
YES
NO
HAVE YOU EVER APPLIED TO OR WORKED FOR OUR COMPANY BEFORE?
*
YES
NO
IF "YES", WHEN?
POSITION DESIRED
COMPANY APPLYING TO
*
Please Select
Premier Smiles Orthodontics
Growing Smiles Children's Dentistry
VIP Dental Assisting School
POSITION APPLYING FOR
*
POSITION APPLYING FOR
Please Select
Front Desk
Orthodontic Assistant
Manager
Engagement & Outreach Coordinator - Marketing
PSO
POSITION APPLYING FOR
Please Select
Front Desk
Dental Assistant
Manager
GS
POSITION APPLYING FOR
Please Select
Dental Assisting Instructor
Program Director
VIP
Date
*
-
Month
-
Day
Year
Date
DESIRED SALARY
*
EDUCATION / TRAINING / SKILLS
HIGH SCHOOL
*
LOCATION
*
CITY & STATE
NUMBER OF YEARS
*
GRADUATE?
*
YES
NO
SUBJECTS STUDIED
*
COLLEGE
*
LOCATION
*
CITY & STATE
NUMBER OF YEARS
*
GRADUATE?
*
YES
NO
SUBJECTS STUDIED
*
OTHER
LOCATION
CITY & STATE
NUMBER OF YEARS
GRADUATE
YES
NO
SUBJECTS STUDIED
SPECIAL/RELEVANT SKILL & TRAINING, OR MEMBERSHIPS
MILITARY SERVICE
BRANCH
FROM - TO
RANK AT DISCHARGE
TYPE OF DISCHARGE
INTERNAL REFERENCES
PLEASE LIST ANY RELATIVES OR FRIENDS THAT ARE CURRENTLY EMPLOYED BY PREMIER SMILES ORTHODONTICS, GROWING SMILES CHILDREN'S DENTISTRY, INNOVATIVE SMILES CLE, OR VIP DENTAL ASSISTING SCHOOL
FULL NAME
*
FULL NAME
Last Name
TITLE
*
RELATIONSHIP
*
FULL NAME
*
FULL NAME
Last Name
TITLE
*
RELATIONSHIP
*
FULL NAME
*
FULL NAME
Last Name
TITLE
*
RELATIONSHIP
*
CRIMINAL HISTORY
Some cities and states prohibit prospective employers from asking whether an applicant has been convicted of a crime at the beginning of the application process. Do not provide conviction information if located in California, Connecticut, District of Columbia, Hawaii, Illinois, Baltimore MD, Montgomery County MD, Prince George’s County MD, Massachusetts, Minnesota, New Jersey, Buffalo NY, New York City NY, Oregon, Philadelphia PA, Austin TX, Vermont, Seattle WA, Spokane WA, or other jurisdictions where prohibited.
IN THE LAST 7 YEARS, HAVE YOU BEEN CONVICTED OF A CRIME, EXCLUDING MISDEMEANORS, WHICH HAS NOT BEEN ANNULLED, EXPUNGED, OR SEALED BY A COURT?
*
YES
NO
IF YES, DESCRIBE IN FULL
EMPLOYMENT HISTORY
COMPANY
*
PHONE NUMBER
*
PLEASE ENTER A VALID PHONE NUMBER
START DATE
*
-
Month
-
Day
Year
Date
END DATE
*
-
Month
-
Day
Year
Date
PAY
Some cities and states prohibit prospective employers from asking for applicants’ salary histories. Do not provide pay information if located in California, Delaware, Massachusetts (eff. 7/1/18), New York City NY, Oregon (eff. 1/1/2019), Philadelphia PA, Puerto Rico, or other jurisdictions where prohibited.
ADDRESS
*
CITY & STATE
SUPERVISOR
*
MAY WE CONTACT YOUR EMPLOYER
*
YES
NO
JOB TITLE
*
RESPONSIBILITIES
*
REASON FOR LEAVING
*
COMPANY
*
PHONE
*
PLEASE ENTER A VALID PHONE NUMBER
START DATE
*
-
Month
-
Day
Year
Date
END DATE
*
-
Month
-
Day
Year
Date
PAY
Some citiesand states prohibit prospective employers from asking for applicants’ salary histories. Do not provide pay information if located in California, Delaware, Massachusetts (eff. 7/1/18),New York City NY, Oregon (eff. 1/1/2019), Philadelphia PA, Puerto Rico, or other jurisdictions where prohibited.
ADDRESS
*
CITY & STATE
SUPERVISOR
*
MAY WE CONTACT YOUR PREVIOUS EMPLOYER?
*
YES
NO
JOB TITLE
*
RESPONSIBILITIES
*
REASON FOR LEAVING
*
COMPANY
*
PHONE NUMBER
*
PLEASE ENTER A VALID PHONE NUMBER
START DATE
*
-
Month
-
Day
Year
Date
END DATE
*
-
Month
-
Day
Year
Date
PAY
Some cities and states prohibit prospective employers from asking for applicants’ salary histories. Do not provide pay information if located in California, Delaware, Massachusetts (eff. 7/1/18), New York City NY, Oregon (eff. 1/1/2019), Philadelphia PA, Puerto Rico, orother jurisdictions where prohibited.
ADDRESS
*
CITY & STATE
SUPERVISOR
*
MAY WE CONTACT YOUR PREVIOUS EMPLOYER?
*
YES
NO
JOB TITLE
*
RESPONSIBILITIES
*
REASON FOR LEAVING
*
PROFESSIONAL REFERENCES
PLEASE LIST THREE PROFESSIONAL REFERENCES NOT RELATED TO YOU
FULL NAME
*
FULL NAME
Last Name
TITLE
*
PHONE NUMBER
*
PLEASE ENTER A VALID PHONE NUMBER
RELATIONSHIP
*
COMPANY
*
ADDRESS
*
CITY & STATE
YEARS ACQUAINTED
*
FULL NAME
*
FULL NAME
Last Name
TITLE
*
Phone Number
*
Please enter a valid phone number.
RELATIONSHIP
*
COMPANY
*
ADDRESS
*
CITY & STATE
YEARS ACQUAINTED
*
FULL NAME
*
FULL NAME
Last Name
TITLE
*
Phone Number
*
Please enter a valid phone number.
RELATIONSHIP
*
COMPANY
*
ADDRESS
*
CITY & STATE
YEARS ACQUAINTED
*
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I understand that completion of this Application does not constitute an offer of employment. I certify that all information provided herein is true, correct, and complete. I understand that, if employed, any false information, misstatements, omissions, or misrepresentations on this Application may result in my dismissal. I authorize the investigation of all statements contained herein and give the references and employers listed above permission to provide all pertinent information concerning my previous employment. If employed, I agree to follow the COMPANY's rules and regulations and I understand and agree that the terms of my employment maychange, with or without notice, at any time. I further understand thatacceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future or for a specific length of time, and I agree that employment may be terminated, with or without cause, with or without notice, by either myself or the COMPANY at any time.
YES
TODAY'S DATE
*
-
Month
-
Day
Year
APPLICATION DATE
SIGNATURE
*
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