Employment Opportunities Thank you for your interest in becoming a part of the Agnini Family Dental family. Please fill out our application for dental office employment and we will get back to you. Employment Application Step 1 of 6 16% Date MM slash DD slash YYYY For what position are you applying? Personal DetailsName First Middle Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneEmail Are you at least 18 years old? Yes No (if no, please provide a work permit)Do you have the legal right to work in the U.S.? Yes No Experience and SkillsOffice SkillsKeyboard SkillsNoneNoviceFairGoodExcellentBookkeepingNoneNoviceFairGoodExcellentComputerNoneNoviceFairGoodExcellentWord ProcessingNoneNoviceFairGoodExcellentExcelNoneNoviceFairGoodExcellentSingle/Multi-line Phone SkillsNoneNoviceFairGoodExcellentOSHA & Safety RegulationsNoneNoviceFairGoodExcellentAccount CollectionsNoneNoviceFairGoodExcellentTreatment PresentationNoneNoviceFairGoodExcellentFee PresentationNoneNoviceFairGoodExcellentDental TerminologyNoneNoviceFairGoodExcellentInsurance ProcessingNoneNoviceFairGoodExcellentAppointment SchedulingNoneNoviceFairGoodExcellentChartingNoneNoviceFairGoodExcellent Clinical SkillsCPR TrainingNoneNoviceFairGoodExcellentTray SetupNoneNoviceFairGoodExcellent4-handed DentistryNoneNoviceFairGoodExcellent6-handed DentistryNoneNoviceFairGoodExcellentTake, Process X-raysNoneNoviceFairGoodExcellentPour and Trim ModelsNoneNoviceFairGoodExcellentCoronal PolishNoneNoviceFairGoodExcellentFabricate Temporary CrownsNoneNoviceFairGoodExcellentCement Temporary CrownsNoneNoviceFairGoodExcellentTooth WhiteningNoneNoviceFairGoodExcellentPlaque Control InstructionsNoneNoviceFairGoodExcellentPeriodontic SkillsNoneNoviceFairGoodExcellentOrthodontic SkillsNoneNoviceFairGoodExcellent EducationHigh School Number of Years AttendedGraduate? Yes College Number of Years AttendedGraduate? Yes Course or Major Post Graduate Number of Years AttendedGraduate? Yes Course or Major Special Courses or Training Number of Years AttendedGraduate? Yes Course or Major Certificates or LicensesX-RAY Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY DA Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY RDA Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY RDA/EF Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY RDH Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY RDH/EF Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY COR POL Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY CPR Yes No Certificate/License # Date Earned MM slash DD slash YYYY State Issued Expiration Date MM slash DD slash YYYY General InformationCan you fulfill the job duties and responsibilities of the position for which you are applying as they have been described to you, with or without a reasonable accommodation? Yes No Are you available for the work hours required of the position for which you are applying? Yes No Select the days of the week you will NOT be available to work:MondayTuesdayWednesdayThursdayFridaySaturdaySundayHold Command and click to select multiple days.If applicable, do you have the required license(s) to perform the job? Yes No Date available to start? MM slash DD slash YYYY Salary Requirements per hour/day/month Employment / Work Experience List the last 7 years of employment, self-employment or unemployment.Name of Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSupervisor's Name Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Position(s) Held Your Last Name at Time of Employment Describe Your DutiesGive Specific Reason(s) for Leaving May we contact this employer? Yes No Name of Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSupervisor's Name Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Position(s) Held Your Last Name at Time of Employment Describe Your DutiesGive Specific Reason(s) for Leaving May we contact this employer? Yes No Name of Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneSupervisor's Name Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Position(s) Held Your Last Name at Time of Employment Describe Your DutiesGive Specific Reason(s) for Leaving May we contact this employer? Yes No Please read the following and sign below EQUAL OPPORTUNITY EMPLOYER We are an equal opportunity employer. We do not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, veteran status, or any other characteristic protected by law. GENERAL AGREEMENT If hired, I will provide legal proof of identity and authority to work in the United States. I agree to conform to the rules and standards of the business, as amended from time to time at the employer's discretion. I understand that any misrepresentation, falsification, or omission of material information on this application may result in my failure to receive an offer, or, if I am hired, in my dismissal from employment. I hereby certify that the information contained in this application form is true and correct to the best of my knowledge. EMPLOYMENT RELATIONSHIP If hired, I understand that employment is not for a specified term and can be terminated “at-will”, with or without cause, and with or without notice, at any time, either at the option of the employee or the employer. No employee or representative of the business, other than its owner, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the employer may not alter the “at-will” nature of the employment relationship unless it is done specifically in writing and is signed by the employer. I agree that this constitutes a final and fully binding agreement with respect to the “at-will” nature of my employment relationship. There are no oral or collateral agreements regarding this issue. REFERENCE AND BACKGROUND CHECKING All offers of employment are conditioned upon satisfactory completion of a background and reference check. Qualified applicants may also be required to submit to a pre-employment drug screen and/or medical exam. If these become part of the screening process, I understand I must complete appropriate documentation for these to occur. Applicant's Signature Date MM slash DD slash YYYY This application for employment is good for 30 days only. Consideration for employment after 30 days requires a new application. Δ SCHEDULE A CONSULTATION TODAY! Contact Us