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ANDERSON TOWNSHIP
FAIRFAX/MARIEMONT
HILLIARD
WEST CHESTER
Employment Application
Job Application – Complete
Step
1
of
8
12%
YOUR INFORMATION
AN EQUAL OPPORTUNITY EMPLOYER: EMPLOYER DOES NOT DISCRIMINATE IN EMPLOYMENT BECAUSE OF RACE, COLOR, SEX, RELIGION, NATIONAL ORIGIN, AGE, DISABILITY, MARITAL STATUS, OR ELIGIBILITY FOR SERVICES IN THE ARMED FORCES OF THE UNITED STATES.
YOUR NAME
*
First
Middle
Last
OTHER NAMES USED
EMAIL
*
PHONE
*
ADDRESS
*
Street Address
Address Line 2
City
Alabama
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Armed Forces Americas
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Armed Forces Pacific
State
ZIP Code
POSITION DESIRED
*
Salary/Wage Desired
Date Available
MM slash DD slash YYYY
Job Location
*
ANDERSON, OHIO
FAIRFAX / MARIEMONT, OHIO
WEST CHESTER, OHIO
USE THE NEXT AND PREVIOUS BUTTONS AT THE BOTTOM OF THE FORM TO NAVIGATE THE ONLINE APPLICATION.
BACKGROUND INFORMATION
PERSON/ORGANIZATION RESPONSIBLE FOR REFERRAL
If a newspaper ad, please tell us the newspaper
WERE YOU REFERRED BY A CURRENT ADVANCE DENTISTRY EMPLOYEE?
NO
YES
WHO WAS THE ADVANCE DENTISTRY EMPLOYEE THAT REFERRED YOU
ARE YOU LEGALLY ALLOWED TO WORK IN THE UNITED STATES?
*
YES
NO
If hired, Federal law requires documentation verifying your identity and legal authorization to work in the U.S. Employment is dependent upon proof of citizenship, employment authorization, or presentation of an alien registration number.
ARE YOU 16 YEARS OF AGE OR OLDER
*
YES
NO
TYPE OF EMPLOYMENT DESIRED (check all that apply)
*
Full Time
Part Time
Temp/Seasonal
On-Call
WHAT DAYS ARE YOU AVAILABLE TO WORK (check all that apply)
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
WHAT SHIFTS ARE YOU AVAILABLE TO WORK (check all that apply)
Morning
Afternoon
Evening
LIST ANY OTHER EDUCATION, TRAINING, SPECIAL SKILLS, OR CERTIFICATES THAT YOU POSSESS RELATED TO THE JOB FOR WHICH YOU ARE APPLYING
HAVE YOU APPLIED OR WORKED HERE BEFORE
YES
NO
WHEN DID YOU APPLY OR WORK HERE
EDUCATIONAL BACKGROUND
HIGH SCHOOL EDUCATION COMPLETED OR GED PASSED
*
YES
NO
EDUCATION: HIGHEST LEVEL GRADE COMPLETED
9TH – HIGH SCHOOL
10TH – HIGH SCHOOL
11TH – HIGH SCHOOL
12TH – HIGH SCHOOL
PROFESSIONAL DEGREE / BACKGROUND
1) COLLEGE/UNIVERSITY/TRADE SCHOOL
CITY/STATE
UNITS
DEGREE/DIPLOMA
MAJOR
COMPLETED
YES
NO
2) COLLEGE/UNIVERSITY/TRADE SCHOOL
CITY/STATE
UNITS
DEGREE/DIPLOMA
MAJOR
COMPLETED
YES
NO
MILITARY BACKGROUND
US MILITARY SERVICE
YES
NO
MILITARY BRANCH
RANK
DATE OF SERVICE
WORK HISTORY
Start with your most recent employment; include self-employment, military and voluntary experience. This section must be completed even if submitting a resume.
EMPLOYER – CURRENT / MOST RECENT
COMPANY NAME
*
JOB TITLE
Date Started
Date Ended
COMPANY ADDRESS
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
JOB DUTIES
SUPERVISOR
REASON FOR LEAVING
MAY WE CONTACT
YES
NO
CONTACT NAME
DENTAL LICENSES AND CERTIFICATIONS
Please enter License #, Date Earned, State Issued, and Current through Date
DO YOU HAVE DENTAL LICENSES AND OR CERTIFICATIONS?
YES
NO
X-RAY
CDA
EDDA/RDA
RDH
CPR
HIPAA
OTHER
OFFICE SKILLS
DO YOU HAVE OFFICE SKILLS
YES
NO
TYPING (skill level)
FAIR
GOOD
EXCELLENT
BOOKKEEPING (skill level)
FAIR
GOOD
EXCELLENT
COMPUTERS (skill level)
FAIR
GOOD
EXCELLENT
ACCOUNT/COLLECTIONS (skill level)
FAIR
GOOD
EXCELLENT
TAX PRESENTATIONS (skill level)
FAIR
GOOD
EXCELLENT
FEE PRESENTATIONS (skill level)
FAIR
GOOD
EXCELLENT
DENTAL TERMINOLOGY (skill level)
FAIR
GOOD
EXCELLENT
INSURANCE PROCESSING (skill level)
FAIR
GOOD
EXCELLENT
SCHEDULING (skill level)
FAIR
GOOD
EXCELLENT
CUSTOMER SERVICES (skill level)
FAIR
GOOD
EXCELLENT
CHARTING (skill level)
FAIR
GOOD
EXCELLENT
MANAGEMENT (skill level)
FAIR
GOOD
EXCELLENT
CLINICAL SKILLS
DO YOU HAVE CLINICAL SKILLS
YES
NO
TRAY SETUP (skill level)
FAIR
GOOD
EXCELLENT
FOUR-HANDED DENTISTRY (skill level)
FAIR
GOOD
EXCELLENT
SIX-HANDED DENTISTRY (skill level)
FAIR
GOOD
EXCELLENT
TAKE, DEVELOP, MOUNT X-RAYS (skill level)
FAIR
GOOD
EXCELLENT
POUR AND TRIM MODELS (skill level)
FAIR
GOOD
EXCELLENT
CORONAL POLISH (skill level)
FAIR
GOOD
EXCELLENT
FABRICATE/CEMENT TEMP CROWNS (skill level)
FAIR
GOOD
EXCELLENT
OSHA AND SAFEST REGULATIONS (skill level)
FAIR
GOOD
EXCELLENT
PLAQUE CONTROL INSTRUCTIONS (skill level)
FAIR
GOOD
EXCELLENT
PERIODONTAL SKILLS (skill level)
FAIR
GOOD
EXCELLENT
ORTHODONTIC SKILLS (skill level)
FAIR
GOOD
EXCELLENT
ORAL SURGERY ASSISTING (skill level)
FAIR
GOOD
EXCELLENT
PLEASE LIST LANGUAGES SPOKEN FLUENTLY, OTHER THAN ENGLISH
PLEASE LIST ANY ADDITIONAL PERTINENT SKILLS, SPECIAL TRAINING, CERTIFICATIONS OR QUALIFICATIONS
PLEASE LIST ANY OTHER ACCOMPLISHMENTS, AWARDS, PROFESSIONAL GROUPS OF WHICH YOU ARE A MEMBER, OR ADDITIONAL INFORMATION YOU LIKE US TO CONSIDER
UPLOAD YOUR RESUME IF APPLICABLE
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Consent
*
IMPORTANT – READ BEFORE SIGNING
I certify that the information in this application is true and complete. Any false statements, concealments or omissions are grounds for refusal to hire or for immediate dismissal if hired.
I authorize Advance Dentistry® to investigate and verify the information contained in this application which may include contacting my schools and former employers, and for Advance Dentistry® to keep and preserve such records.
I understand that if hired, my employment is at will and may be terminated by either the Company or me, without cause and without notification.
THIS APPLICATION DOES NOT CONSTITUTE A CONTRACT FOR EMPLOYMENT, EXPRESSED OR IMPLIED.
If employed, I agree to adhere to the Company’s Rules and Regulations.
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