Application for Dental Office Employment
Date: _______________ What position are you applying for?_____________________________________
Name:
Telephone: (home)
Address (number, street, city, state, zip)
Telephone: (business)
Social Security Number
Telephone: (cell)
Do you have the legal right to work in the US? YES NO
Email address:
Work permit: Type of verification:
Are you: left handed right handed
If you are bi-lingual, what languages do you
Speak____________________ Read ____________________ Write ____________________
Experience and Skills
Have you had experience in the following:
What is your skill level?
Yes
No
Fair
Good
Excellent
Typing
Computerized bookkeeping
In-home computer
Ten-key adding machine
Account collections
Treatment presentation
Fee presentation
Dental terminology
Insurance processing
Appointment scheduling
Dental charting
CPR training
Procedure tray setups
Four handed dentistry
Six handed dentistry
Take, develop, mount xrays
Pour up and trim models
Coronal polish
Fabricate temporary crowns
Cement temporary crowns
Oral hygiene instruction (plaque control)
Expanded periodontic skills
Expanded orthodontic skills
E.D.D.A. certified by State of Louisiana
Patterson Eaglesoft Software
Dexis Digital X-ray Software
Other:
Education History
Location:
Dates attended:
Degree/Certificate:
Grade completed:
Major:
Major:
Major:
Major:
Dental Certificates or Licenses
License #
Date earned
State issued
X-ray
CDA
EDDA/RDA
RDH
RDH/EF
Coronal Polish
CPR
Others
Post graduate seminars taken in the last 2 years:
__________________________________________________________________________________________
__________________________________________________________________________________________
Are all certifications current? YES NO
Do you have any physical condition whish could (1) limit your ability to perform the job applied for, (2) be
aggravated by the job you have applied for? YES NO
If yes, explain: _____________________________________________________________________________
Are you taking medication at the present time that could limit your ability to perform the job applied for?
YES NO
Should you be hired, may we have your permission to talk with your physician?
YES NO
Physician’s name: _______________________________ Telephone (_______) __________________
How much work time have you lost because of illness in the last 2 years? ______________________________
Check times willing to work:
Days
Evenings
No. of days per week ________
Full time
Part time
Hours per week _________
Circle days of the week you will NOT be available for work:
Monday Tuesday Wednesday Thursday Friday
Can your future vacations be arranged at office convenience? YES NO
If no, explain: ______________________________________________________________________________
If offered employment, when can you start? ______________________________________________________
Salary requirement: _________________________________________________________________________
Fringe benefit requirements:
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever been convicted of a felony? YES NO
If yes, explain:
__________________________________________________________________________________________
__________________________________________________________________________________________
A conviction record will not necessarily be a bar to employment.
Employment History
List present or most recent position first. Cover last 7 years, including periods of self-employment, or
unemployment. Fill in all information – DO NOT SUBSTITUTE WITH A RESUME
May we contact your present employer? YES NO
Name of employer:
Supervisor’s name:
Supervisor’s title:
Address:
Phone numbers:
Your last name at time of employment:
Position:
Describe major duties:
Specific reason for leaving:
Employed from: _____________
to: _____________
Total years employed: _____________
Total months employed: _____________
Beginning salary or wages: $
Ending salary or wages: $
Name of employer:
Supervisor’s name:
Supervisor’s title:
Address:
Phone numbers:
Your last name at time of employment:
Position:
Describe major duties:
Specific reason for leaving:
Employed from: _____________
to: _____________
Total years employed: _____________
Total months employed: _____________
Beginning salary or wages: $
Ending salary or wages: $
Name of employer:
Supervisor’s name:
Supervisor’s title:
Address:
Phone numbers:
Your last name at time of employment:
Position:
Describe major duties:
Specific reason for leaving:
Employed from: _____________
to: _____________
Total years employed: _____________
Total months employed: _____________
Beginning salary or wages: $
Ending salary or wages: $
Character References
(other than relatives and past employers)
Name:
Address:
Telephone numbers:
Email address:
Name:
Address:
Telephone numbers:
Email address:
Character References
Name:
Address:
Telephone numbers:
Email address:
General Agreement
I understand that any misrepresentation, falsification, or material omission of information on this application
may result in my failure to receive an offer or, if I am hired, my dismissal from employment. I understand that
all offers of employment are conditioned on my legal authority to work in the United States. In consideration of
my employment, I agree to conform to the rules and standards of the practice, as amended from time to time in
its discretion.
Authorization to check references
I hereby certify that the information contained in this application form is true and correct to the best of my
knowledge and agree to have any of the statements checked unless I have indicated to the contrary. I authorize
the references listed above, as well as all other individuals who you may contact provide any and all
information concerning my previous employment and any other pertinent information that they may have.
Further, I release all parties and persons from any and all liability for any damages that may result from
furnishing such information as well as from the use or disclosure of such information by the employer or any of
its agents, employees, or representatives.
At-will employment relationship
I agree that my employment can be terminated at will, with or without cause, and with or without notice, at any
time, either at my option or at the option of the employer. I understand that no employee or representative of
the practice, other than its owner(s), 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 owner(s) of the
practice may not alter the at-will nature of the employment relationship unless it is done specifically and in
writing that is signed.
______________________________________________________________________________________
Applicant signature date
Please complete the following information in your own handwriting. PLEASE DO NOT PRINT.
1. Describe the responsibilities on your present or last job. Please give a detailed response to this and the
following questions.
2. What factors would contribute to your sense of satisfaction on a job?
3. What aspects of working with people do you find enjoyable, and what, if any, do you find less
enjoyable?
4. What specific aspects of your education or experience do you consider to be beneficial to this position?
PLEASE SIGN YOUR NAME BELOW.