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
