Dental Professional – Smiles Office Staffing

First Name

Last Name

DOB

Phone Number

Address

City

State

Zip Code

Emergency Contact:

Name

Phone/Mobile

Are you a U.S. citizen?

Yes

If No, Are You Authorized To Work In The U.S.?

Yes

Position applying for (Please choose an option to properly complete the application)

Receptionist

Dental Assistant

Hygienist

Educational Background / Professional Information

Receptionist

College

Degree(s)

Year Graduated

Hygienist

College

Degree(s)

Year Graduated

RDH License #

Professional Liability Policy #

Specialty in (check all that applies):

General

Periodontal

Pediatric

Certification(s) (check all that applies):

Nitrous

Local Anesthetic

CPR

Other:

Please specify

Digital X-ray Software:

Dexis

Kodak

Schick

Other:

Please specify

Assistant

College

Degree(s)

Year Graduated

Certification(s) (check all that applies):

CPR

Nitrous Monitor

IV Sedation

Coronal Polishing

Computer Systems Proficient at

Preferences

Interested in

Temporary Placement

Permanent Placement

Full Time

Part Time

Preferred Geographic Area

Preferred Method of Contact

SMS

Phone Number

I have been vaccinated for Hepatitis B Virus

Yes

If Yes, when?

Covid Vaccine

Yes

Languages Spoken

Please write a brief paragraph about yourself (i.e., workplace likes and dislikes, your interests…)

Employment History

Current or Most Recent Employer

May we contact the employer for reference?

Yes

Dates Employed

Employer Address

Phone Number

Reason for Leaving

Previous Employer

Dates Employed

Employer Address

Phone Number

Reason for Leaving

References

Please list at least two professional references who has worked with you directly.

Name

Phone Number

Name

Phone Number

Name

Phone Number

I, certify that the facts contained in this registration are true and complete to the best of my knowledge and understand that, if hire, falsified statement on this registration can be grounds for dismissal.

I give Smiles Office Staffing, LLC permission to contact references and verify information given to them and authorize disclosure of this information to Clients as needed in the hiring process.

Signature

Sign Here

Date

Attach a copy of your resume

Choose File

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Are you a new graduate? Are you looking for flexibility?

Do you want to be part of a tailor-made team?

Dental Professional Application