Employment Application

    An Equal Opportunity Employer

    Important: there are 2 pages to this application and until you press SUBMIT, your data would not saved.

    Date Last Name First Name Middle
     

    Present Address

    No. & Street City State Zip
     

    Permanent Address (if different from present address)

    No. & Street City State Zip
     
    Phone Number Email Alternate Contact Method Preferred Contact: Time & Method
     

    Employment Desired

    Position applying for
     

    Are you applying for:

    Regular full-time work?
    YesNo
    Regular part-time work?
    YesNo
    Temporary work, e.g., summer or holiday work?
    YesNo
     
    What days and hours are you available for work?
     

    If applying for temporary work, during what period of time will you be available?

    From: To:
     
    Are you available for work on weekends?
    YesNo
    Would you be available to work overtime, if necessary?
    YesNo
     
    If hired, on what date can you start work?
    Salary desired


    Personal Information

    Have you ever worked for Santa Teresa Dental before?
    YesNo
        If yes, when?
     
    Do you have any friends or relatives working for Santa Teresa Dental?
    YesNo
        

    If yes, state name(s) and relationship:

        Name Relationship
        Name Relationship
     

    Why are you applying for work at Santa Teresa Dental?

     
    If hired, would you have a reliable means of transportation to and from work?
    YesNo
    Are you at least 18 years old? (If under 18, hire is subject to verification that you are of minimum legal age.)
    YesNo
    If hired, can you present evidence of your U.S. citizenship or proof of your legal right to live and work in this country?
    YesNo
     
    Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
    YesNo
        If no, describe the functions that cannot be performed.

    (Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

     
    Are you currently employed?
    YesNo
        If so, may we contact your current employer?
    YesNoN/A
     

    Education, Training, and Experience

    High School

    Name No. of Years Completed Did you graduate?
    YesNo
    Degree or Diploma
    Address
    City State Zip
     

    College/University

    Name No. of Years Completed Did you graduate?
    YesNo
    Degree or Diploma
    Address
    City State Zip
     

    Vocational/Business

    Name No. of Years Completed Did you graduate?
    YesNo
    Degree or Diploma
    Address
    City State Zip
     

    Health Care Training

    Name No. of Years Completed Did you graduate?
    YesNo
    Degree or Diploma
    Address
    City State Zip
     

    Seminar & C.E. Courses attended in the last 2 years

     
    Option: Many of our customers (clients) do not speak English. Do you speak, write or understand any foreign languages?
    YesNo
        If yes, which languages?
     
    Do you have any other experience, training, qualifications, or skills that you feel make you especially suited for work at Santa Teresa Dental?
    YesNo
        If so, please explain?
     

    Answer the following questions if you are applying for a professional position:

    Are you licensed/certified for the job applied for?
    YesNo
        Name of license/certification: Issuing state: License/certification number:
     

    Has your license/certification ever been revoked or suspended?
    YesNo

    If yes, state reason(s), date of revocation or suspension, and date of reinstatement