APPLICATION FOR DENTAL OFFICE EMPLOYMENT

* Required fields

For which position are you applying?
Name:
Social Security No.:
Work Permit No.: (if a minor and if applicable)
Telephone: Home:
  Business:
Address: Street:
  City:
  Zip Code:
Can you legally work in the United States? (please provide proof)
Have you ever been convicted of a felony?
If you are bilingual, what languages do you speak, read, or write?

EXPERIENCE AND SKILLS
Have you had experience in the following: (Check the last column space if NOT within last three years)
  Experience Years Prior to 3 Years
Typing (W.P.M)
One-write bookkeeping (peg board)
Computerized bookkeeping
Account collections
Treatment presentation
Free presentation
Charting
Dictation equipment
Six handed assisting
Four handed assisting
Dental terminology
Take, develop and mount x-rays
Pour and trim models
Fabricate temporary crowns
Tray set-up
Coronal polishing
Plaque control instructions
Expanded periodic skils

EDUCATION
Last high school attended Location Check last grade completed

COLLEGE, TRADE SCHOOL OR SPECIAL TRAINING
Name of school Location Dates Attended Degrees / Certificate Major

DENTAL CERTIFICATES OR LICENSES (Dates Earned)
X-Ray: CDA:
EDDA/RDA: RDH:
DH/EF: Coronal polish:
Others:
Post graduate seminars taken in the last 2 years:
Do you have any physical condition which could (1) limit your ability to perform the job applied for or (2) be aggravated by the job you have applied for?
If yes, explain
Are you taking medication at the present time that could limit your ability to perform the job applied for?
Should you be hired, may we have your permission to talk with your physician?
Physician's name: Telephone:
Check time willing work:


No. of days per week


Hours per week:
If offered employment, when can you start?
Have you given notice to your present employer?
Have you ever been bonded?
Do you know of any reason why you cannot be bonded?
Salary requirement:
Check days of week you will not be avaliable for work:





Can your future vacations be arranged at convenience of the office?
Do you have any fringe benefit needs?
Please explain:
Are you...
Do you smoke?
What is your anticipated length of employment?
PREVIOUS EMPLOYMENT
 
List present, or most recent, position first. Please cover last 10 years of employment. Resume may be substituted for employment history detail.
May we contact your present employer?
 
1.
Name of Employer:
Your last name while employed:
Address:
Telephone Number:
Position:
Description of your job:
Dates of employment: Date Separated:
Date Hired:
Length of employment: Years Months
Earnings: Salary when hired $:
Salary at separation $:
Reason for leaving:
Supervisor's Name:
Title:

2.
Name of Employer:
Your last name while employed:
Address:
Telephone Number:
Position:
Description of your job:
Dates of employment: Date Separated:
Date Hired:
Length of employment: Years Months
Earnings: Salary when hired $:
Salary at separation $:
Reason for leaving:
Supervisor's Name:
Title:

3.
Name of Employer:
Your last name while employed:
Address:
Telephone Number:
Position:
Description of your job:
Dates of employment: Date Separated:
Date Hired:
Length of employment: Years Months
Earnings: Salary when hired $:
Salary at separation $:
Reason for leaving:
Supervisor's Name:
Title:

4.
Name of Employer:
Your last name while employed:
Address:
Telephone Number:
Position:
Description of your job:
Dates of employment: Date Separated:
Date Hired:
Length of employment: Years Months
Earnings: Salary when hired $:
Salary at separation $:
Reason for leaving: