Contact Information

Name
Address
Address
City
State
Zip Code
Social Security #
Work Phone
Home Phone
FAX
E-mail (for us to contact you)

           Were You Ever Known to Any School, Employer, Agency, or Reference by Another name?

Yes No     

        If Yes, Indicate What Name:

Educational Information

Highest Level of Completed Education:

GED High School Diploma  Some College Associate Degree
Bachelor Degree Some Post Graduate Masters Degree Doctorate Degree

Name and Location (City) of High School

Colleges Attended and Major and Degree or Credits Hours Earned   

                                                                                                                                     Degree or

         College/University                                                                Major/Focus             Credit Hrs 

          1.                

           2.               

           3.               

Trade (Vocational) Education /Training , Field, Focus or Certifications, and/or Licenses:

Describe Any Job-Related Training Received:

Special Skills, Accomplishments, Awards, Certificates, and Licenses

Employment  Experience  

Are You Currently Employed?     Yes No  

           May We Contact Your Current Supervisor? Yes No   

   If Yes,   Name and Contact Number

  If No ,    Reason Why:                      

Are You Currently on "Lay-Off" Status Subject to Recall?    Yes No

Work Experience

Start With Your Present or Last Job. Include Any Job Related Assignments or Volunteer Activities You May Feel are Relevant.

   1.Employer & Location       

             Position  Responsibilities  

             Starting Date         Ending Date   

             Starting Salary       Ending Salary

              Reason for Leaving

   2.Employer & Location       

             Position   Responsibilities  

             Starting Date         Ending Date   

             Starting Salary       Ending Salary

             Reason for Leaving

   3.Employer & Location       

              Position   Responsibilities  

             Starting Date         Ending Date   

             Starting Salary       Ending Salary

             Reason for Leaving

   4.Employer & Location       

              Position  Responsibilities  

                   Starting Date         Ending Date   

                   Starting Salary       Ending Salary

                   Reason for Leaving

Personal/Professional References (Do Not Include Relatives):

        Name                                                                Telephone #                    Relationship

1.       

2.       

3.       

4.       

List Professional Licenses and Associations

List Involvement in Community and Civic Organizations & Activities and Offices Held.

Your Knowledge, Experience, and Proficiency  

The Purpose of This Section is to Establish an Entry Level Base of Your Knowledge, Experience, and Proficiency in Various Functions that May be Used in Some Tasks in Our Dental Practice. Remember That No One is Expected to have Knowledge or Experience in All of these Areas. If You Are Hired This Information is Used to Help Formulate an Appropriate Training  Program for Your New Position.

Please Rate Yourself  in the Following Areas on a Scale of 1-5 With the following Meanings : 

        1- No Experience or Knowledge

        2-Minimal Understanding

        3-Basic Knowledge

        4-Moderate Experience 

        5-Advanced Proficiency 

General Office Skills:

1 2 3 4 5

Communication Skills:

1 2 3 4 5

Marketing and Public Relations Skills:

1 2 3 4 5

Bookkeeping Skills:

            1 2 3 4 5

Typing Skills:

1 2 3 4 5

Telephone, Intercom, and Voice Mail Systems:

1 2 3 4 5

Dental / Medical Terminology:

1 2 3 4 5

Benefits (Insurance) Knowledge:

1 2 3 4 5

Patient Care:

            1 2 3 4 5

Computer Skills

Computers in General:

1 2 3 4 5

Computer Hardware:

          1  2  3  4  5    

Windows Operating System (Windows2000, Windows XP):

1 2 3 4 5

MS Word (Word Processing):

1 2 3 4 5

Digital Photography:

1 2 3 4 5

Scanning Photographs and Documents:

1 2 3 4 5

Internet Use (Internet Explorer):

1 2 3 4 5

Email Correspondence:

1 2 3 4 5

MS Outlook/ Outlook Express:

1 2 3 4 5

Network Operating System (Windows NT/2000):

1 2 3 4 5

Position Desired 

Administrative/Business/Desk Staff
Clinical Assistant
Hygienist
Dentist
Maintenance
Other

Are You Able to Occasionally Attend Continuing Professional Education Requiring Out of Town Overnight Travel?

Yes No

What is Your Desired Salary Range?   

If You are Hired,  When Would You Be Available for Work? 

Other Information:

Other Qualifications and Information You Would Like Us to Know About:

Applicant’s Statement

By submitting this form, I certify that answers given herein are true and complete to the best of my knowledge and authorize investigation of all statements contained in this application for employment, as may be necessary in arriving at an employment decision.

I hereby understand and acknowledge by submitting this form that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.  It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interviews may result in immediate discharge.  I understand, also, that I am required to abide by all rules and regulations of the employer.

 

Please print a copy of this application for your records.