APPLICANT CONTACT INFORMATION
Name*
First Middle Last
Other Names Used
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Email Address*
QUESTIONS ABOUT APPLICANT
Position Desired*
Date Available*
Date Format: MM slash DD slash YYYY
Type of employment desired*
- Full Time
- Part Time
- Temp/Seasonal
- On-Call
What days are you available to work (check all that apply)*
- Sun
- Mon
- Tues
- Wed
- Thurs
- Fri
- Sat
What shifts are you available to work (check all that apply)*
- Morning
- Afternoon
- Evening
Are you legally eligible for employment in the United States?*
- Yes
- No
(Proof of U.S. citizenship or immigration status will be required upon employment)
Are you 16 years of age or older*
- Yes
- No
Have you applied or worked here before?*
- Yes
- No
when?
How did you hear about this position?
EDUCATIONAL BACKGROUND
High School Education or GED passed?*
- Yes
- No
Please indicate highest grade completed:*
- 8
- 9
- 10
- 11
- 12
EDUCATIONAL BACKGROUND
College/University/Trade School City/State Units Degree/Diploma Major Completed
US Military Service
US Military Service Branch Rank Dates of Service
EMPLOYMENT HISTORY
List all positions held, including part-time summer and/or volunteer work and periods of employment for the last ten years; do not omit any employers. Explain any gaps in employment in comment section. If you are submitting a resume, you are still required to provide the requested information in the space provided. If self-employed, provide company name and at least two business references. Attach additional sheets or continue on the back of the page, if needed.
Current Employer
Employer Name
Dates Employed From
Date Format: MM slash DD slash YYYY
Dates Employed To
Date Format: MM slash DD slash YYYY
May We Contact?*
- Yes
- No
Contact Name
Telephone
Address
Job Title
Reason for Leaving
Responsibilities
Previous Employer
Employer Name
Dates Employed From
Date Format: MM slash DD slash YYYY
Dates Employed To
Date Format: MM slash DD slash YYYY
May We Contact?*
- Yes
- No
Contact Name
Telephone
Address
Job Title
Reason for Leaving
Responsibilities
Have another previous employer?
- Have another previous employer?
Section Break
Previous Employer
Employer Name
Dates Employed From
Date Format: MM slash DD slash YYYY
Dates Employed To
Date Format: MM slash DD slash YYYY
May We Contact?*
- Yes
- No
Contact Name
Telephone
Address
Job Title
Reason for Leaving
Responsibilities
SPECIAL TRAINING AND SKILLS
Dental Licenses & Certifications - X-Ray
License #
Date Earned
Date Format: MM slash DD slash YYYY
State Issued
Current through Date
Date Format: MM slash DD slash YYYY
Dental Licenses & Certifications - CDA
License #
Date Earned
Date Format: MM slash DD slash YYYY
State Issued
Current through Date
Date Format: MM slash DD slash YYYY
Dental Licenses & Certifications - EDDA/RDA
License #
Date Earned
Date Format: MM slash DD slash YYYY
State Issued
Current through Date
Date Format: MM slash DD slash YYYY
Dental Licenses & Certifications - RDH
License #
Date Earned
Date Format: MM slash DD slash YYYY
State Issued
Current through Date
Date Format: MM slash DD slash YYYY
Dental Licenses & Certifications - CPR
License #
Date Earned
Date Format: MM slash DD slash YYYY
State Issued
Current through Date
Date Format: MM slash DD slash YYYY
Dental Licenses & Certifications - HIPAA
License #
Date Earned
Date Format: MM slash DD slash YYYY
State Issued
Current through Date
Date Format: MM slash DD slash YYYY
Dental Licenses & Certifications - Other
License #
Date Earned
Date Format: MM slash DD slash YYYY
State Issued
Current through Date
Date Format: MM slash DD slash YYYY
Office Skill
Y/N Skill Level (Fair/Good/Excellent)
Office Skill
Typing
Y/N Skill Level (Fair/Good/Excellent)
Bookkeeping
Y/N Skill Level (Fair/Good/Excellent)
Computers
Y/N Skill Level (Fair/Good/Excellent)
Account/Collections
Y/N Skill Level (Fair/Good/Excellent)
Tax Presentation
Y/N Skill Level (Fair/Good/Excellent)
Fee Presentation
Y/N Skill Level (Fair/Good/Excellent)
Dental Terminology
Y/N Skill Level (Fair/Good/Excellent)
Insurance Processing
Y/N Skill Level (Fair/Good/Excellent)
Scheduling
Y/N Skill Level (Fair/Good/Excellent)
Customer Service
Y/N Skill Level (Fair/Good/Excellent)
Charting
Y/N Skill Level (Fair/Good/Excellent)
Management
Y/N Skill Level (Fair/Good/Excellent)
Clinical Skill
Tray Setup
Y/N Skill Level (Fair/Good/Excellent)
Four-handed Dentistry
Y/N Skill Level (Fair/Good/Excellent)
Six-handed Dentistry
Y/N Skill Level (Fair/Good/Excellent)
Take, Develop, Mount X-rays
Y/N Skill Level (Fair/Good/Excellent)
Pour & Trim Models
Y/N Skill Level (Fair/Good/Excellent)
Coronal Polish
Y/N Skill Level (Fair/Good/Excellent)
Fabricate/Cement Temp Crowns
Y/N Skill Level (Fair/Good/Excellent)
OSHA & Safest Regulations
Y/N Skill Level (Fair/Good/Excellent)
Plaque Control Instructions
Y/N Skill Level (Fair/Good/Excellent)
Periodontal Skills
Y/N Skill Level (Fair/Good/Excellent)
Orthodontic Skills
Y/N Skill Level (Fair/Good/Excellent)
Oral Surgery Assisting
Y/N Skill Level (Fair/Good/Excellent)
Please list languages spoken fluently, other than English
Please list any additional pertinent skills, special training, certifications or qualifications
Please list any other accomplishments, awards, professional groups of which you are a member, or additional information you would like us to consider
I certify that my answers are true and complete to the best of my knowledge.*
- I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I further understand that any employment that is offered to me will be at-will and that this application does not create or imply a contract for employment.
Applicant Signature
Date
Date Format: MM slash DD slash YYYY

Contact

23 US-46, Hackettstown, NJ 07840
(908) 979-9779
info@westmorrisdental.com

Hours

Monday 9 AM–7 PM
Tuesday 10 AM–8 PM
Wednesday 9 AM–7 PM
Thursday 9 AM–6 PM
Friday 8 AM–1 PM
Saturday Closed
Sunday Closed

Directions

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College/University/Trade School	City/State	Units	Degree/Diploma	Major	Completed

US Military Service	Branch	Rank	Dates of Service

Application For Employment Dental

APPLICANT CONTACT INFORMATION

QUESTIONS ABOUT APPLICANT

EDUCATIONAL BACKGROUND

EMPLOYMENT HISTORY

Current Employer

Previous Employer

Section Break

Previous Employer

SPECIAL TRAINING AND SKILLS

Dental Licenses & Certifications - X-Ray

Dental Licenses & Certifications - CDA

Dental Licenses & Certifications - EDDA/RDA

Dental Licenses & Certifications - RDH

Dental Licenses & Certifications - CPR

Dental Licenses & Certifications - HIPAA

Dental Licenses & Certifications - Other

Office Skill

Clinical Skill

Contact

Hours

Directions

Follow Us!