APPLICATION FOR DENTAL OFFICE EMPLOYMENT

Date:______________________ For what position are you applying? ___________________________________

Last Name First Middle

Address (number, city, state, zip) Are you at least 18 years old? [ ] Yes [ ] No

(if no, please provide work permit)

Cell Phone: (_______)________________________

Home Phone: (_______)______________________

Do you have the legal right to work in the U.S.? [ ] Yes [ ] No

EXPERIENCE AND SKILLS

OFFICE SKILLS

Yes

WHAT IS YOUR

SKILL LEVEL?

CLINICAL SKILLS

Yes

WHAT IS YOUR

SKILL LEVEL?

Fair Good Exc. Fair Good Exc.

Keyboard Skills

CPR Training

Bookkeeping

Tray Setup

Computer

4-handed Dentistry

Word Processing

6-handed Dentistry

Excel

Take, Process X-rays

Single/Multi-line Phone Skills

Pour and Trim Models

OSHA & Safety Regulations

Coronal Polish

Account Collections

Fabricate Temporary Crowns

Treatment Presentation

Cement Temporary Crowns

Fee Presentation

Tooth Whitening

Dental Terminology

Plaque Control Instructions

Insurance Processing

Periodontic Skills

Appointment Scheduling

Orthodontic Skills

Charting

EDUCATION

Name of School and Address Graduated # of Years Course or Major

High School

Y / N

College

Y / N

Post Graduate

Y / N

Special Courses or Training

Y / N

Additional

Special Courses or Training

Y / N

CERTIFICATES OR LICENSES

X-RAY DA RDA RDA/EF RDH RDH/EF COR POL CPR Other

Certificate/License #

Date Earned

State Issued

Expiration Date

APPLICATION FOR

DENTAL OFFICE EMPLOYMENT

Office 800-679-2760 § Version 17.20.2 Form #

102D

GENERAL INFORMATION

Can you fulfill the job duties and responsibilities of the position for which you are

applying as they have been described to you, with or without a reasonable

accommodation? [ ] Yes [ ] No

Are you available for the work hours required of the position for which you are

applying? [ ] Yes [ ] No

Circle the days of the week you will NOT be available to work: Mon Tue Wed Thu Fri Sat Sun

If applicable, do you have the required license(s) to perform the job? [ ] Yes [ ] No

Date available to start? Salary requirements:$_________ per hour/day/month

EMPLOYMENT / WORK EXPERIENCE

List the last 7 years of employment, self-employment or unemployment—do not substitute with a resume. Attach additional pages if needed.

Name of Employer:

Address (number, city, state, zip): Phone:

Employed: From and To (month and year)

Supervisor’s Name:

Average # of Hours Worked Per Week:

Positions(s) Held: Your Last Name at Time of Employment:

Describe Your Duties:

Give Specific Reason(s) for Leaving:

May we contact this employer: [ ] Yes [ ] No

Name of Employer:

Address (number, city, state, zip): Phone:

Employed: From and To (month and year)

Supervisor’s Name:

Average # of Hours Worked Per Week:

Positions(s) Held: Your Last Name at Time of Employment:

Describe Your Duties:

Give Specific Reason(s) for Leaving:

May we contact this employer: [ ] Yes [ ] No

Name of Employer:

Address (number, city, state, zip): Phone:

Employed: From and To (month and year)

Supervisor’s Name:

Average # of Hours Worked Per Week:

Positions(s) Held: Your Last Name at Time of Employment:

Describe Your Duties:

Give Specific Reason(s) for Leaving:

May we contact this employer: [ ] Yes [ ] No

APPLICATION FOR

DENTAL OFFICE EMPLOYMENT

Office 800-679-2760 § Version 17.20.2 Form #

102D

Name of Employer:

Address (number, city, state, zip): Phone:

Employed: From and To (month and year)

Supervisor’s Name:

Average # of Hours Worked Per Week:

Positions(s) Held: Your Last Name at Time of Employment:

Describe Your Duties:

Give Specific Reason(s) for Leaving:

May we contact this employer: [ ] Yes [ ] No

PLEASE READ THE FOLLOWING AND SIGN BELOW

EQUAL OPPORTUNITY EMPLOYER

We are an equal opportunity employer. We do not discriminate against otherwise qualified applicants on the basis of race, color, creed,

religion, ancestry, age, sex, marital status, national origin, disability or handicap, veteran status, or any other characteristic protected by law.

GENERAL AGREEMENT

If hired, I will provide legal proof of identity and authority to work in the United States. I agree to conform to the rules and standards of the

business, as amended from time to time at the employer's discretion. I understand that any misrepresentation, falsification, or omission of

material information on this application may result in my failure to receive an offer, or, if I am hired, in my dismissal from employment. I

hereby certify that the information contained in this application form is true and correct to the best of my knowledge.

EMPLOYMENT RELATIONSHIP

If hired, I understand that employment is not for a specified term and can be terminated “at-will”, with or without cause, and with or without

notice, at any time, either at the option of the employee or the employer. No employee or representative of the business, other than its

owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to

the foregoing. Further, the employer may not alter the “at-will” nature of the employment relationship unless it is done specifically in writing

and is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the “at-will” nature of my

employment relationship. There are no oral or collateral agreements regarding this issue.

REFERENCE AND BACKGROUND CHECKING

All offers of employment are conditioned upon satisfactory completion of a background and reference check. Qualified applicants may also

be required to submit to a pre-employment drug screen and/or medical exam. If these become part of the screening process, I understand I

must complete appropriate documentation for these to occur.

Applicant’s signature:___________________________________________ Date:______________________

This application for employment is good for 30 days only.

Consideration for employment after 30 days requires a new application.

APPLICATION FOR

DENTAL OFFICE EMPLOYMENT

Office 800-679-2760 § Version 17.20.2 Form #

102D