23 Route 46 East, Hackettstown, NJ 07840
(908) 979-9779
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23 Route 46 East, Hackettstown, NJ 07840
(908) 979-9779
Facebook
Instagram
Appointment
23 US-46, Hackettstown, NJ 07840
(908) 979-9779
Facebook
Instagram
Appointment
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General Dentistry
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Home
About Us
Service Area
General Dentistry
Dental Crowns And Bridges
Root Canals
Preventative Dental Care
Tooth Extractions
Nitrous Oxide
Fillings
Cosmetic Dentistry
Teeth Whitening
Invisalign
Discoloration Treatment
Patient Resources
Pay Bill
Insurance
Health History
Accessibility
Join Our Team
Orthodontic Partners
Testimonials
Gallery
Contact Us
Application For Employment Dental
APPLICANT CONTACT INFORMATION
Name
*
First
Middle
Last
Other Names Used
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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
