Job Application

Personal Information

First Name*

Last Name*

Address*

City*

State*

Zip Code*

Home Phone*

Email Address*

Marital Status

MarriedSingleDivorcedWidowed

Are You a US Citizen?

YesNo

If no, do you have legal right to work in the US?

YesNo

Have you ever been convicted of a crime?

YesNo

If convicted of a crime, please explain

Do you have a physical/mental condition which could (1) limit your ability to perform the job applied for or (2) be aggravated by performing the job applied for?

YesNo

If you answered yes above, please explain

Do you have dependable means of transportation?

YesNo

How did you hear about us?

Employment Desired

What position would you like to apply for?

Dental AssistantDental HygienistOffice Administration

When can you start?

Desired Salary

Are you currently employed? YesNo

May we contact your current employer?

YesNo

Have you ever applied at this office before?

YesNo

If yes, when did you last apply?

What type of employment are you seeking?

Full-timePart-time

If part-time, what are your available hours?

Do you have any special skills, experience or other training which would make you the ideal candidate for our office? If so, please explain?

Education & Certification

Employment History

General Agreement

I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my dismissal from employment. I understand that all offers of employment are conditioned on my legal authority to work in the United States. In consideration of my employment, I agree to conform to the rules and standards of the practice, as amended from time to time in its discretion.

Authorization to Check References

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals who you may contact provide any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information as well as from the use or disclosure of such information by the employer or any of its agents, employees, or representatives.

Certification and Agreement

By clicking submit below, you agree to the terms above. Please read carefully.