Application For Employment Dental

Application For Employment Dental
Name
Name
First
Middle
Last
Address
Address
City
State/Province
Zip/Postal
Country

QUESTIONS ABOUT APPLICANT

Type of employment desired
What days are you available to work (check all that apply)
What shifts are you available to work (check all that apply)
Are you legally eligible for employment in the United States?

(Proof of U.S. citizenship or immigration status will be required upon employment)

Are you 16 years of age or older
Have you applied or worked here before?

EDUCATIONAL BACKGROUND

High School Education or GED passed?

Repeater

Repeater

EMPLOYMENT HISTORY

List all positions held, including part-time summer and/or volunteer work and periods of employment for the last ten years; do not omit any employers. Explain any gaps in employment in comment section. If you are submitting a resume, you are still required to provide the requested information in the space provided. If self-employed, provide company name and at least two business references. Attach additional sheets or continue on the back of the page, if needed.

Current Employer

May We Contact?

Previous Employer

May We Contact?

SPECIAL TRAINING AND SKILLS

Dental Licenses & Certifications - X-Ray

Dental Licenses & Certifications - CDA

Dental Licenses & Certifications - EDDA/RDA

Dental Licenses & Certifications - RDH

Dental Licenses & Certifications - CPR

Dental Licenses & Certifications - HIPAA

Dental Licenses & Certifications - Other

Office Skill

Typing

Bookkeeping

Computers

Account/Collections

Tax Presentation

Fee Presentation

Dental Terminology

Insurance Processing

Scheduling

Customer Service

Charting

Management

Clinical Skill

Tray Setup

Four-handed Dentistry

Six-handed Dentistry

Take, Develop, Mount X-rays

Pour & Trim Models

Coronal Polish

Fabricate/Cement Temp Crowns

OSHA & Safest Regulations

Plaque Control Instructions

Periodontal Skills

Orthodontic Skills

Oral Surgery Assisting

Certification