6065 S Redwood Rd.
Taylorsville, UT 84123
(801) 268-2323
pinecrestdds.com
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Employment Application
Applying For :
-- Select --
Office Manager
Dental Assistant
Dental Hygienist
General Dentist
Marketing Assistant
Treatment Coordinator
Scheduling Coordinator
Customer Service
Superstar Sales
After Hours Appointment Scheduler
Billing Coordinator
Personal Assistant
Other
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
State
ZIP Code
Phone:
Email
Date Available:
Desired Salary:
$
Position Applied for:
Are you a citizen of the United States?
Yes
No
If no, are you authorized to work in the U.S.?
Yes
No
Have you ever been convicted of a felony?
Yes
No
If yes, explain:
High School:
Address:
From:
To:
Did you graduate?
Yes
No
Diploma:
College:
Address:
From:
To:
Did you graduate?
Yes
No
Degree:
Other:
Address:
From:
To:
Did you graduate?
Yes
No
Degree:
Please list three professional references.
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Full Name:
Relationship:
Company:
Phone:
Address:
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Signature for authorization to contact previous employer
Company:
Phone:
Address:
Supervisor:
Job Title:
Starting Salary:
$
Ending Salary:
$
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
Yes
No
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
1.
2.
3.
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.
Signature:
Date:
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