EMPLOYMENT APPLICATION

Transcription

1 EMPLOYMENT APPLICATION POSITION APPLYING FOR: DATE: NAME: LAST FIRST MI HOME PHONE: CELL PHONE: address: CURRENT ADDRESS: STREET HOW LONG: CITY STATE ZIP PRIOR ADDRESS: HOW LONG: STREET CITY STATE ZIP EMERGENCY CONTACT:

2 AVAILABILITY What date are you available to start? What category would you prefer? Full time Part time Temporary What days of the week are you available? Monday Tuesday Wednesday Thursday F Friday JOB-RELATED SKILLS Computer skills: Dental software: PROFESSIONAL LICENSES AND CERTIFICATIONS Are you licensed/certified for the job applied for? Yes No Name of license/certifications: License/certification number: Issuing State: Has your license/certification ever been revoked or suspended? Yes No If yes, state the reason(s), date of revocation or suspension, and date of reinstatement: Please give a description of what teamwork means to you?

3 TRAINING AND EXPERIENCE Please indicate in which of the following functions you have received formal training and the amount of experience in a dental office you have had performing each function. If you are qualified in more than one of the classifications below, please indicate. DENTAL ASSISTANTS & HYGIENIST PROFICIENCY: HIGH LOW Administer anesthetic (hygienists) CAD/CAM digital impression / crown fabrication Digital X-ray processing Packing cord Impressioning and study model preparation Photography with mirrors and DSLR Camera Rubber dam placement Restoring teeth with composite Seating and adjusting crowns Invisalign training CDT Codes Nitrous Certification Typing skills FRONT DESK Typing Billing (speed per minute) Proficiency: High Low Completing Insurance Forms Knowledge of dental terms & instruments

4 OFFICE VISION The purpose of our office is to promptly serve our neighbors with a compassionate, professional, and friendly attitude as we provide comprehensive, quality, predictable, and long-lasting dentistry to achieve optimum oral health. We promise our patients we will relentlessly pursue excellence in our individual fields through consistent daily improvement. We commit to continually educate ourselves in order to assist patients in making accurate decisions for their oral health. Their treatment and care will be catered to their needs. We promise each other we will work as a high performance team in an environment of mutual respect. We enjoy our work, we value each other, and we cherish our patients in order to achieve our number one goal--to create a positive and memorable dental experience. In so doing we hope to be a positive contributing member in our community and sphere of influence both personally and professionally. Please give a description of how you would actively participate in the success of this vision. REFERENCES Name Phone # Years Known EDUCATION Name City & State Graduate Y N Degree Type High School College

5 EMPLOYMENT HISTORY Most Recent Employer: Employer: Phone: Address: Position Title: Starting salary Ending Salary Dates: From To Supervisor: Reason for leaving: Are you currently working for this employer? Yes No If yes, may we contact them? Yes No Second Most Recent Employer: Employer: Phone: Address: Position Title: Starting salary Ending Salary Dates: From To Supervisor: Reason for leaving: Third Most Recent Employer: Employer: Phone: Address: Position Title: Starting salary Ending Salary Dates: From To Supervisor: Reason for leaving:

6 CRIMINAL HISTORY Have you ever been convicted of a crime? Yes No Please explain a yes answer. Are you currently awaiting trial for any criminal offense? Yes No Please explain a yes answer. APPLICANT NOTE This application form is intended for use in evaluating your qualifications for employment. This application form is not an offer of employment. If hired, such employment shall be considered at will and this application is not intended to constitute a contract of continued employment. False or misleading statements during the interview or on this form may result in the refusal to hire or termination of employment. Applicants are considered for positions without discrimination of the basis of race, color, religion, sex, national origin, age, disability, or any other consideration made unlawful by applicable federal, state or local laws. Additional testing of job-related skills and for the presence of drugs in your body may be required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. CERTIFICATION AND RELEASE I certify that I have read and understand the applicant note on this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application of discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any of this information. I release all former employer, persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. SIGNATURE DATE

7 Name: Date: Math Test Calculator is allowed. Please sum the following ledgers: Charters Jones Flacks Cooper Cohen Smith Caroline Hawes Edwards Phillips Kemper Brown Charles Pitt Marshall Mack O Hara Sorenson Myers MacDonald Rodriguez Check-Out Questions: Ms. Smith has a treatment plan totaling $1, Her insurance will cover 75% of the total cost. What is her obligation? $ Andy Wright qualifies for a Senior Citizen discount of 10% on his bill of $ Rounding the discount up to the nearest whole dollar, what is the total amount due? $

8 Employment Expectation Worksheet Rank the following descriptive words from 1 to 12, with 1 being the most important and 12 being the least important, regarding what you are looking for in an employment opportunity. Feedback Hours to Fit My Schedule Career Advancement (opportunity for growth) Friendly Co-workers New Skills / Continuing Education To Be Appreciated Performance Objectives Opportunity for impacting others Compensation structure (guarantee vs. bonus) Job Security Quality of the product/service we provide Location Picking Pairs Task: Take a look at the rows of numbers below. In each row, you must circle pairs of adjacent numbers that add up to 10. For example: in this line: There are four pairs

9 Please read through the following list of values, circling the top five that you ALWAYS value. Place your top five in rank order in the space available below. Family Service Spiritual Growth Friendship Prosperity Personal Development Teamwork Competence Knowledge Integrity Challenge Accountability Communication Helping Creativity Recognition Health Security Play Fairness Neatness Solutions Tolerance Technology Self-Awareness Achieving Goals Hard Work 1) 2) 3) 4) 5)