Employment Application

    We are an equal opportunity employer and do not discriminate on the basis of race, religion, color, national origin, age, sex, gender, disability, or any other reason prohibited under Federal, State, or local laws.

    APPLICANT CONTACT INFORMATION

    QUESTIONS ABOUT APPLICANT

    EDUCATIONAL BACKGROUND

    EMPLOYMENT HISTORY

    List all positions held, including part-time summer and/or volunteer work and periods of employment for the last ten years; do not omit any employers. Explain any gaps in employment in comment section. If you are submitting a resume, you are still required to provide the requested information in the space provided. If self-employed, provide company name and at least two business references. Attach additional sheets or continue on the back of the page, if needed.

    Employer

    Dates Employed

    May We Contact

    SOCIAL TRAINING AND SKILLS

    Dental Licenses & Certificates

    X-Ray

    CDA

    EDDA/RDA

    RDH

    CPR

    HIPAA

    Other

    Office Skill

    Typing

    Bookkeeping

    Computers

    Account/ Collections

    Tax Presentation

    Fee Presentation

    Dental Terminology

    Insurance Processing

    Scheduling

    Customer Service

    Charting

    Management

    Clinical Skill

    Tray Setup

    Four-Handed Dentistry

    Six-Handed Dentistry

    Take, Develop, Mount X-Ray

    Pour & Trim Models

    Coronal Polish

    Fabricate/Cement Temp Crowns

    OSHA & Safest Regulations

    Plaque Control Instructions

    Periodontal Skills

    Orthodontic Skills

    Oral Surgery Assisting