Application for Employment Please enable JavaScript in your browser to complete this form. – Step 1 of 9Contact InformationName *FirstLastOther Names UsedAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell Phone *Home PhoneEmail *NextQuestions About ApplicantWhat position are you applying for? *HygienistDental AssistantExperience CoordinatorPatient Care CoordinatorTreatment CoordinatorInsurance CoordinatorFront Office Team LeadShadowing OpportunityWhat salary/wage range are you looking for? *What type of benefits are you looking for? *What date would you be available to start working? *What kind of employment are you looking for? *Full TimePart TimeTemp/SeasonalOn-CallThis position occasionally requires weekend travel and overtime. Do you have any responsibilities that conflict with these requirements? *What days are you available to work? (check all that apply) *MondayTuesdayWednesdayThursdayFridaySaturdayWhat shifts are you available to work? (check all that apply) *MorningAfternoonEveningWhat is your anticipated length of employment? *Are you legally eligible for employment in the United States? (Proof of US citizenship or immigration status will be required upon employment)YesNoAre you able to perform the essential functions of this job, with or without reasonable accommodation?YesNoAre you 16 years of age or older?YesNoHave you applied or worked here before?YesNoHow did you hear about this position? *NextEducational BackgroundDid you graduate from High School or pass the GED? *YesNoPlease indicate the highest grade completed.8th Grade9th Grade10th Grade11th Grade12th GradePlease note all college, university, or trade schools attended. Indicate the year of graduation if applicable. Are you planning on continuing your studies? If yes, where and what courses of study?In addition to your work history, are there any other skills, qualifications, or experiences that we should consider?NextDo you have previous experience working in a dental office?YesNoDo you have previous experience working in a sales role?YesNoDo you have previous experience working in a call center?YesNoDo you have previous experience working in a management or leadership position?YesNoEmployment HistoryList the last three positions held in the fields below with the most recent job first, 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 the comments section. If you have had additional employers in related fields please include their contact information in the resume you will be submitting at the end. 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. Employer *Is this your current employer? *YesNoSupervisor's contact name at place of employment *FirstLastPhone *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob Title *Reason for Leaving *Responsibilities *Start Date *End DateStarting Salary *Ending Salary *We understand that transitioning between jobs can be tricky. If you would like to request that we do not contact your current employer, this will not jeopardize your application. May we contact your current employer? *YesNoPlease explain why. *Previous Employer Supervisor's contact name at place of employmentFirstLastPhoneAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob TitleReason for LeavingResponsibilitiesStart DateEnd DateStarting SalaryEnding SalaryMay we contact this employer?YesNoPrevious EmployerSupervisor's contact name at place of employmentFirstLastPhoneAddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeJob TitleReason for LeavingResponsibilitiesStarting DateEnding DateStarting SalaryEnding SalaryMay we contact this employer?YesNoPlease provide any additional pertinent information below.NextReferencesPlease provide three references who are not related to you and who are not your previous employers. Name *FirstLastRelation to you *Phone *Name *FirstLastRelation to you *Phone *Name *FirstLastRelation to you *Phone *NextSpecial Training and SkillsPlease list any pertinent certifications and licenses with the license or certification number, date earned, and expiration date (for example: CPR, HIPAA, X-Ray CDA, Expanded Duty, RDA, RDH).Please list languages spoken fluently, other than English.Please list pertinent skills, special training, and equipment you are trained to operate.Please list any other accomplishments, awards, professional groups of which you are a member, or additional information you would like us to consider.NextWritten InterviewWhat are you most proud of in your career to date? *Describe a situation where you were faced with a real challenge and came through for both yourself and your company. *Give an example of a time that you have been criticized for your work. How did you respond and why? *What is your interpretation of success? *NextPlease upload your resume here.Resume (PDF files only) * Click or drag a file to this area to upload. NextI certify that my answers are true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application. I authorize my previous employers, schools, or persons listed as references to give any information regarding employment or educational record. I agree that this company and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by myself on this application. In the event of any employment with this company, I will comply with all rules and regulations as set by the company in any communication distributed to the employees. In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide approved documentation to the company that verifies my right to work in the United States on the first day of employment. I have received from the company a list of the approved documents that are required. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I further understand that any employment that is offered to me will be at-will and that this application does not create or imply a contract for employment. Signature * Clear Signature DateAuthorization to conduct reference checksBy signing below, applicant hereby grants his/her knowing and voluntary release of the above named Former Employer, its employees, officers, directors, and shareholders, from any and all liability for any damages, foreseeable or not, arising out of the furnishing of employment history information to the above named Requesting Company. Applicant voluntarily and knowingly authorizes the above named Former Employer to release any and all information concerning his/her current or former employment with it. Applicant understands that the employment information from the Former Employer may include, but is not necessarily limited to, performance evaluations and reports, job descriptions, disciplinary reports, letters of reprimand, and opinions regarding suitability for employment possessed, whether or not it was substantiated by written documentation. Signature * Clear Signature DateEmailSubmit Application
