Application For Employment Dental "*" indicates required fields APPLICANT CONTACT INFORMATIONName* First Middle Last Other Names Used Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone*Email Address* QUESTIONS ABOUT APPLICANTPosition Desired* Date Available* MM slash DD slash YYYY Type of employment desired* Full Time Part Time Temp/Seasonal On-Call What days are you available to work (check all that apply)* Sun Mon Tues Wed Thurs Fri Sat What 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 when? How did you hear about this position? EDUCATIONAL BACKGROUNDHigh School Education or GED passed?* Yes No Please indicate highest grade completed:* 8 9 10 11 12 EDUCATIONAL BACKGROUNDCollege/University/Trade SchoolCity/StateUnitsDegree/DiplomaMajorCompleted YesNo Add RemoveUS Military ServiceUS Military ServiceBranchRankDates of Service YesNo Add RemoveEMPLOYMENT HISTORYList 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 EmployerEmployer Name Dates Employed From MM slash DD slash YYYY Dates Employed To MM slash DD slash YYYY May We Contact?* Yes No Contact Name TelephoneAddress Job Title Reason for Leaving Responsibilities Previous EmployerEmployer Name Dates Employed From MM slash DD slash YYYY Dates Employed To MM slash DD slash YYYY May We Contact?* Yes No Contact Name TelephoneAddress Job Title Reason for Leaving Responsibilities Have another previous employer? Have another previous employer? HiddenSection BreakPrevious EmployerEmployer Name Dates Employed From MM slash DD slash YYYY Dates Employed To MM slash DD slash YYYY May We Contact?* Yes No Contact Name TelephoneAddress Job Title Reason for Leaving Responsibilities SPECIAL TRAINING AND SKILLSDental Licenses & Certifications - X-RayLicense # Date Earned MM slash DD slash YYYY State Issued Current through Date MM slash DD slash YYYY Dental Licenses & Certifications - CDALicense # Date Earned MM slash DD slash YYYY State Issued Current through Date MM slash DD slash YYYY Dental Licenses & Certifications - EDDA/RDALicense # Date Earned MM slash DD slash YYYY State Issued Current through Date MM slash DD slash YYYY Dental Licenses & Certifications - RDHLicense # Date Earned MM slash DD slash YYYY State Issued Current through Date MM slash DD slash YYYY Dental Licenses & Certifications - CPRLicense # Date Earned MM slash DD slash YYYY State Issued Current through Date MM slash DD slash YYYY Dental Licenses & Certifications - HIPAALicense # Date Earned MM slash DD slash YYYY State Issued Current through Date MM slash DD slash YYYY Dental Licenses & Certifications - OtherLicense # Date Earned MM slash DD slash YYYY State Issued Current through Date MM slash DD slash YYYY HiddenOffice Skill Y/N Skill Level (Fair/Good/Excellent) Office SkillTyping Y/N Skill Level (Fair/Good/Excellent) Bookkeeping Y/N Skill Level (Fair/Good/Excellent) Computers Y/N Skill Level (Fair/Good/Excellent) Account/Collections Y/N Skill Level (Fair/Good/Excellent) Tax Presentation Y/N Skill Level (Fair/Good/Excellent) Fee Presentation Y/N Skill Level (Fair/Good/Excellent) Dental Terminology Y/N Skill Level (Fair/Good/Excellent) Insurance Processing Y/N Skill Level (Fair/Good/Excellent) Scheduling Y/N Skill Level (Fair/Good/Excellent) Customer Service Y/N Skill Level (Fair/Good/Excellent) Charting Y/N Skill Level (Fair/Good/Excellent) Management Y/N Skill Level (Fair/Good/Excellent) Clinical SkillTray Setup Y/N Skill Level (Fair/Good/Excellent) Four-handed Dentistry Y/N Skill Level (Fair/Good/Excellent) Six-handed Dentistry Y/N Skill Level (Fair/Good/Excellent) Take, Develop, Mount X-rays Y/N Skill Level (Fair/Good/Excellent) Pour & Trim Models Y/N Skill Level (Fair/Good/Excellent) Coronal Polish Y/N Skill Level (Fair/Good/Excellent) Fabricate/Cement Temp Crowns Y/N Skill Level (Fair/Good/Excellent) OSHA & Safest Regulations Y/N Skill Level (Fair/Good/Excellent) Plaque Control Instructions Y/N Skill Level (Fair/Good/Excellent) Periodontal Skills Y/N Skill Level (Fair/Good/Excellent) Orthodontic Skills Y/N Skill Level (Fair/Good/Excellent) Oral Surgery Assisting Y/N Skill Level (Fair/Good/Excellent) 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 considerI certify that my answers are true and complete to the best of my knowledge.* 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 Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
