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