Employment Application

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 State ZIP Code
POSITION DESIRED*
Salary/Wage Desired
Date Available
Date Format: MM slash DD slash YYYY
Job Location*
- ANDERSON, OHIO
- FAIRFAX / MARIEMONT, OHIO
- WEST CHESTER, OHIO
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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)
BOOKKEEPING (skill level)
COMPUTERS (skill level)
ACCOUNT/COLLECTIONS (skill level)
TAX PRESENTATIONS (skill level)
FEE PRESENTATIONS (skill level)
DENTAL TERMINOLOGY (skill level)
INSURANCE PROCESSING (skill level)
SCHEDULING (skill level)
CUSTOMER SERVICES (skill level)
CHARTING (skill level)
MANAGEMENT (skill level)
CLINICAL SKILLS
DO YOU HAVE CLINICAL SKILLS
- YES
- NO
TRAY SETUP (skill level)
FOUR-HANDED DENTISTRY (skill level)
SIX-HANDED DENTISTRY (skill level)
TAKE, DEVELOP, MOUNT X-RAYS (skill level)
POUR AND TRIM MODELS (skill level)
CORONAL POLISH (skill level)
FABRICATE/CEMENT TEMP CROWNS (skill level)
OSHA AND SAFEST REGULATIONS (skill level)
PLAQUE CONTROL INSTRUCTIONS (skill level)
PERIODONTAL SKILLS (skill level)
ORTHODONTIC SKILLS (skill level)
ORAL SURGERY ASSISTING (skill level)

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
Drop files here or
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.
CAPTCHA
ENTER YOUR LEGAL NAME BELOW FOR DIGITAL SIGNATURE*

YOUR INFORMATION