Employment Application

Southern Arizona Endodontics Employment Application

Southern Arizona Endodontics does not discriminate on the basis of race, religion, national origin, color, gender, age, or disability. It is our intention that all applicants be given equal opportunity and that selection decisions are based on job related factors.

First Name(Required)

Last Name(Required)

Home Phone(Required)

Other Phone

Email(Required)

Address

Street Address Address Line 2 City State ZIP Code

Employment preferences and questions

Position you are applying for:(Required)

Will you work evenings?

Will you work occasional Saturdays?

What is your reason for desiring employment?(Required)

Have you ever applied for a position at Southern Arizona Endodontics?

Have you ever been convicted of a felony?

Date you can start(Required)

Hourly wage desired(Required)

How would you rate your computer proficiency (scale of 1-5 with 1 being little experience and 5 being expert)?

Dentrix

Microsoft Word

Microsoft Excel

Microsoft Outlook

Employment History

Current Employer

Name of Employer(Required)

Name of Supervisor(Required)

Supervisor Phone

May we contact this employer?

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Starting Salary(Required)

Ending Salary(Required)

Start Date(Required)

End Date(Required)

Your last job title(Required)

Job Description/Promotions(Required)

Reason for leaving(Required)

Do you have another employer to add?(Required)

Yes

Employer 2 Name

Employer 2 Supervisor(Required)

Supervisor Phone

May we contact employer 2?

Employer 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Start Date(Required)

End Date(Required)

Starting Salary(Required)

Ending Salary(Required)

Your last job title(Required)

Job Description/Promotions(Required)

Reason for leaving(Required)

Education Information

School Name and Location(Required)

Years Completed(Required)

Diploma/Degree; X-ray Cert. or other Certificates(Required)

Major Course Of Study(Required)

References

Please provide three professional references

Referral 1

Name(Required)

Phone(Required)

Company(Required)

Address | City, State | ZIP

Referral 2

Name(Required)

Phone(Required)

Company(Required)

Address | City, State | ZIP

Referral 3

Name(Required)

Phone(Required)

Company(Required)

Address | City, State | ZIP

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the company from any liability as a result of such contact. I am authorized to work under federal law and agree to any verification required by Southern Arizona Endodontics.

Signature(Required)

Today's Date(Required)

Employment Application

Employment Application

Southern Arizona Endodontics Employment Application

Employment preferences and questions

How would you rate your computer proficiency (scale of 1-5 with 1 being little experience and 5 being expert)?

Employment History

Education Information

References

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