State Avenue Dental Office New Hiring Form

Application form
Applicant information
Applying Position*

Dental AssistantFront DeskBilling & Insurance
Do you have at least 1yr Dental experience?*

YesNo
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Date Available*

MonthDayYear
Date
Select any language you can speak*

EnglishSpanishKoreanportugueseChineseHmongBurmeseOther
Are you a citizen of the United States?*

YesNo
If no, are you authorized to work in the U.S.?

YesNo
Have you ever worked for this company?

YesNo
If yes, when?
Upload your resume here

Cancelof
Disclaimer and Signature
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 resume, application or interview may result in grounds for termination.
Patient or Parent Signature*
Date*

MonthDayYear
Date
Print Full Name*

First NameLast Name
Should be Empty:

Application form