Applicant Contact Information
Name
*
First Name
Middle Name
Last Name
Other Names Used
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Questions About Applicant
Position Desired
*
Date Available
*
-
Month
-
Day
Year
Date
Type of Employment Desired
Full Time
Part Time
Temp/Seasonal
On-Call
Which days are you available to work? (check all that apply)
*
Sun
Mon
Tues
Wed
Thurs
Fri
Sat
Which 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
Educational Background
High School Education or GED passed?
*
Yes
No
Education
Military Service
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
Previous Employer
Special Training And Skills
Dental Licenses & Certifications - X-Ray
Dental Licenses & Certifications - CDA
Dental Licenses & Certifications - EDDA/RDA
Dental Licenses & Certifications - RDH
Dental Licenses & Certifications - CPR
Dental Licenses & Certifications - HIPAA
Dental Licenses & Certifications - Other
Office Skill
Typing
Bookkeeping
Computers
Account/Collections
Tax Presentation
Fee Presentation
Dental Terminology
Insurance Processing
Scheduling
Customer Service
Charting
Management
Clinical Skill
Tray Setup
Four-handed Dentistry
Six-handed Dentistry
Take, Develop, Mount X-rays
Pour & Trim Models
Coronal Polish
Fabricate/Cement Temp Crowns
OSHA & Safest Regulations
Plaque Control Instructions
Periodontal Skills
Orthodontic Skills
Oral Surgery Assisting
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
Agreement
*
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
*
-
Month
-
Day
Year
Date
Submit
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