Employment Application

PERSONAL DATA

Today’s Date

Date Available

Last Name

First Name

Address

City

State

Zip

Home Phone

Cell Phone

SS#

Email Address

Employment desired

Full-time Part-time Temporary

What Position Are You Applying For?

ARE YOU

Over the age of 18? (if no, you may be required to provide work authorization)

Yes No

Legally permitted to work in the United States?

Yes No

A licensed driver? (Answer only if required for the position)

Yes No

Are you currently employed?

Yes No

If yes, why do you wish to make a change?

ADDITIONAL QUALIFICATIONS

What knowledge, special technical or computer skills and/or individual capabilities do you have which especially prepare you for the position for which you are applying?

MILITARY EXPERIENCE

Branch of Service

Date of service:

From

List duties in service, including schools and training

EDUCATION & TRAINING

High School Name & Location

Course Major

Last Completed Yr

Degree

Graduate?

Yes No

College Name & Location

Course Major

Last Completed Yr

Degree

Graduate?

Yes No

Trade/ Tech Name & Location

Course Major

Last Completed Yr

Degree

Graduate?

Yes No

Post Graduate Name & Location

Course Major

Last Completed Yr

Degree

Graduate?

Yes No

All qualified applicants receive consideration for employment without regard to race, religion, gender, pregnancy, sexual orientation, age, national origin, disability , martial, veteran or any other legally protected status.

ADDITIONAL INFORMATION

In less than 100 words, please tell us why you would like to be employed by Dickinson & Branon Dental Care

In less than 100 words, please explain how your personal values will benefit you in your position and our office as a whole

PREVIOUS EMPLOYMENT

NOTE: Starting with most recent position, furnish all information requested. Please provide a complete employment history including explanations for each period of unemployment. A resume providing the information may be attached as a supplement, but NOT in lieu of completing information requested.

Present/ Last Employer

Type of Business

Job Title

Telephone

Address

Supervisor (Name/Position)

From

Description of Job & Duties

Reason for Leaving

Present/ Last Employer

Type of Business

Job Title

Telephone

Address

Supervisor (Name/Position)

From

Have you ever been discharged or asked to resign from any job?

Yes No

If yes, please explain

ADDITIONAL INFORMATION

Mention referral Name

APPLICANT QUESTIONAIRE

How do you feel about explaining clinical dentistry to patients?

Are you easily frustrated?

What type of music do you enjoy?

What color best describes your personality?

How do you feel about television?

What movie have you recently seen and really enjoyed?

What do you like to do in your spare time?

When did you have your last dental examination?

If you received 1 million dollars as a gift, what would you do with it?

What hobbies do you enjoy?

In a paragraph, please describe where you want to be in five years

EMERGENCY CONTACT

In case of an emergency, please indicate who you would like us to contact:

Name

Relationship

Phone

Cell Phone

Address

APPLICATION AGREEMENT & CERTIFICATION

I understand & agree that:
The information I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal of employment or, if discovered once employed, the termination of my employment with Dickinson & Branon Dental Care [the Company]. Any offer of employment I may receive from the Company is contingent upon my successful completion of the Company’s pre-employment screening process, including, but not limited to: the Company’s soliciting and receiving background information and references. In processing my application for employment, the Company may verify all the information provided by me, or may procure, with my consent, information concerning my prior employment, military record, education, driving record and criminal record, if necessary for the position for which I have applied. I authorize and request that all my present and former employers, including supervisors and managers, and any other individuals I have listed as personal references, furnish information about my employment record, including a statement for the reason of termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information. I agree to comply with the policies, rules, regulations and procedures of the Company and understand that my employment and compensation can be terminated with or without cause, reason or advance notice, at any time, at the option of either the Company or myself. I further understand that no manager or representative of the Company, other than the doctors & associated administrative staff, has the authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to the foregoing. I further understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me and the individuals designated above.

Signature: (Please Write Your Full Name)

Date

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