Email (required)
Previous Address (required)
If yes, please explain:
Would transportation be a problem?
Position interested in (required)
Any other position interest? If so, explain:
Dental ReceptionDental AssistingDental HygieneOffice ManagingProperty managementHousekeepingExpanded DutiesRadiology CertifiedInventory (ordering)SchedulingAccounts PayableGeneral LedgerPayroll Taxes Quarterly TaxesBookkeeping
Typing /editing Speed
Menu driven computer Software Type
Will you give at least three-week notice if you find it necessary to leave this employment?
References other than a relatives and past employers (please give name and phone number).
Will you consent to be vaccinated against Hepatitis B? Please selectYesNo
Date of last physical examination:
Have you ever had a major illness or been hospitalized in the last five years? Please selectYesNo
If so, what was the nature of the illness and time lost from work?
Physicians Name:
Telephone:
Address:
Are you taking any medications at this time? Please selectYesNo
If yes, please explain::
When did you have your last dental examination?:
Have you made regular visits to the dentist? Please selectYesNo
Have you lost any teeth? Please selectYesNo
If so, have the teeth been replaced? Please selectYesNo
High School Graduate? Please selectYesNo
College Graduate Please selectYesNo
If so, years completed?
Degree received
Technical School or other
Graduate
Additional credit courses/licenses::
List most recent employment first and account for any time not employed.
2. Employer:
Phone #
Position:
Duties:
Reason for leaving:
May we contact last employer?
3. Employer:
4. Employer:
I authorize performance of a background check. I authorize drug testing at any time.
