Prairie Rose Employment Application

Employment Application

Complete the Information Below
Personal Information
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Birth Date*

MonthDayYear
Are You a U.S. Citizen?*

YesNo
If no, are you authorized to work in the United States?

YesNo
Have you been employed by Prairie Rose Family Dentists previously?*

YesNo
If yes, when were you employed with Prairie Rose?
Have you ever been convicted of a Felony?*

YesNo
If yes, please explain:*
Military Service

If applicable, Thank you for serving our country.
Have you ever served in the United States Military?*

YesNo
If yes, which Branch?*
What was your Military rank at the time of discharge?*
Was your military discharge honorable?*

YesNo
If discharge was anything other than 'honorable', please describe.*
Desired Employment Information

Let's align on the details that matter to you.
Position Applying For*
Verify the job opportunity you are interested in pursuing.
Desired Salary ($)
Tell us your hourly wage requirements, we are listening...
Have you submitted an application to Prairie Rose previously?*

YesNo
Educational Background

Tell us where you went to school.
High School*
Name of High School Attended
Did you receive a high school diploma?*

YesNo
Post Secondary School / College*
Vocational School / College / University you attended and received a degree.
Area of Study / Degree*
If you did not attend, enter "None".
Did you graduate and receive a diploma for your degree?*

YesNo
Additional Skills / Qualifications

Share more about your professional background.
Share any additional certifications, degrees, or continuing education training relevant to your application. (optional)
Share any additional skills or qualifications relevant to your application. (optional)
List any relevant skills
Current Employment

We'd love to hear about your day-to-day!
Current Employer*
Name of current employer, NONE if not employed, STUDENT if currently enrolled in school full time.
Position*
Title of current employment position, or NONE if not employed.
Current Salary ($)
Reason for Leaving?
When did you start working for your current employer?
May We Contact for Reference?

YesNo
Previous Employment

We are interested in your journey.
Previous Employer 1
Name of Previous Employer
Position
Title of current employment position
Previous Salary ($)
Reason for Leaving?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Previous Employer 2
Name of Previous Employer
Position
Previous Salary ($)
Reason for Leaving?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
References

Who is singing your praises? We are listening....
Reference 1*
Name of Reference
Relationship*
Personal or Professional Reference
Years Acquainted*
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Reference 2*
Name of Reference
Relationship*
Personal or Professional Reference
Years Acquainted*
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Referral

How did you hear about this opportunity?
Where did you hear about this job opportunity? *
Internet search, friend, social media, advertisement, etc.
If a Prairie Rose Team member referred you, give them a shout out here.*
If you found us on your own, just enter NONE or NA.
Resume & Cover Letter

Optional, upload if you have one.
Resume

Cancelof
Cover Letter

Cancelof
Submit Application

You are one step closer to joining the Prairie Rose Team.
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
Date

MonthDayYear
Date
Signature

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Employment Application

Personal Information

Military Service

Desired Employment Information

Educational Background

Additional Skills / Qualifications

Current Employment

Previous Employment

References

Referral

Resume & Cover Letter

Submit Application