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Application

Date of Application: Applying For:

Personal Data

Applicant's Name:
Address:
Phone Number: Alternative Phone Number:
Social Security Number: Work Permit:
Emergency Contact:

Current Employment Information

Are you currently employed? Have you given notice to your employer?
May we contact your present employer?
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
(Proof of citizenship or immigration status will be required upon employment.)
If you are under 18 years of age, can you provide required proof of eligibility to work?
On what date would you be available to start work?
Are you available to work:
Number of days per week you can work: Number of hours per week you can work:
What days are you not available to work:
Salary Requirement: Benefit Requirement:
What is your anticipated length of employment?
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, the presence of a non-job related medical condition or handicap, or any other legally protected status.

Education Record

Years Completed (Select) High School
 Undergraduate Trade School or College
 Graduate or Professional
School Name and Location
Diploma / Degree
Specialized Training
Other:
Seminars and CE Courses attended during the last 2 years

Professional Skills

Check yes or no to indicate your experience. Write in the number of years of experience. Write in the year that you last used this skill in the last column, if your experience was prior to three years ago.
Business Yes No Number of Years Last Year Used Clinical Yes No Number of Years Last Year Used
Appointment Scheduling Man. Charting
Appointment Scheduling, Comp. Take, Develop, Mount X-Rays
Pegboard Bookkeeping System Digital Radiography
Computer Bookkeeping System Cosmetic Imaging
Computer Data Entry Pour & Trim Models
Typing Fabricate Temporary Crowns
Operating Recall System 4 Handed Assistant (General)
Billing Assist Crown/Bridge
Accounts Payable Assist Endodontics
Account Collections Assist Oral Surgery
Treatment Presentation Assist Orthodontics
Fee Presentation Assist Operative
Making Financial Arrangements Assist Periodontics
Delinquent Account Contact Assist Pedodontics
Insurance Processing Place Restorations
Dictation Equipment Home Care Instructions
Electronic Claims Transmission Coronal Polishing
Other: Soft Tissue Management
Dental software that you are familiar with: PSR (PerioScreening Recording )
Intraoral Camera

Employment History

List your present or most recent job first. Cover the last 10 years of employment. Include any job-related military service assignments and volunteer activities. Resume may not be substituted. You may exclude organizations which indicate race, color, gender, national origin, handicap or other protected status.
Employer: Dates Employed Work Performed:
From To
Address:
Telephone Number(s): Hourly Rate/Salary
Starting Final
Job Title: Supervisor:
Reason for leaving:
 
Employer: Dates Employed Work Performed:
From To
Address:
Telephone Number(s): Hourly Rate/Salary
Starting Final
Job Title: Supervisor:
Reason for leaving:
 
Employer: Dates Employed Work Performed:
From To
Address:
Telephone Number(s): Hourly Rate/Salary
Starting Final
Job Title: Supervisor:
Reason for leaving:
 
Employer: Dates Employed Work Performed:
From To
Address:
Telephone Number(s): Hourly Rate/Salary
Starting Final
Job Title: Supervisor:
Reason for leaving:

Personal Insight

In your previous positions, what duties did you enjoy doing the most and why?
In your previous positions, what duties did you enjoy doing the least and why?
Describe a career obstacle that you encountered in the past and explain how you overcame it:
Rank the following words from 1-12, with 1 being the most important and 12 being the least important, regarding what you are looking for in an employment opportunity:

References

Give the name, address, email address and phone number of 3 references who are not related to you.

Applicant’s Statement

Name: Date: