Southern Arizona Endodontics Job Application Information Sheet for Candidates Southern Arizona Endodontics does not discriminate on the basis of race, religion, national origin, color, sex, age, or disability. It is our intention that all applicants be given equal opportunity and that selection decisions are based on job related factors. Applicant InfoName* First Last Home Phone*Other Phone NumberEmail* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employment preferences and questionsPosition you are applying for:*CourierDental AssistantFinancial SpecialistInsurance SpecialistPatient CareSelect PositionWill you work on Saturdays?YesNoWill you work evenings?YesNoWhat is your reason for desiring employment?*Have you ever been convicted of a felony?NoYesPlease explain?*Have you ever applied for a position at Southern Arizona Endodontics?NoYesDate you can start* Date Format: MM slash DD slash YYYY Hourly desired*How would you rate your computer proficiency (scale of 1-5)?Dentrix12345Microsoft Outlook12345Microsoft Excel12345Microsoft Word12345How many words per minute can you type?Employment HistoryName of employer*Name of supervisor*Phone*Address*Start Date* Date Format: MM slash DD slash YYYY End Date* Date Format: MM slash DD slash YYYY Starting Salary*Ending Salary*Your last job title*May we contact this employer?YesNoReason for leaving*List the duties performed, skills used, and advancements or promotions while you worked for this company.*Add another employer? Yes Name of employerName of supervisorPhoneAddressStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Starting SalaryEnding SalaryYour last job titleMay we contact this employer?YesNoReason for leavingList the duties performed, skills used, and advancements or promotions while you worked for this company.Add a third employer? Yes Name of employerName of supervisorPhoneAddressStart Date Date Format: MM slash DD slash YYYY End Date Date Format: MM slash DD slash YYYY Starting SalaryEnding SalaryYour last job titleMay we contact this employer?YesNoReason for leavingList the duties performed, skills used, and advancements or promotions while you worked for this company.Education InformationSchool Name and Location*Years Completed*Diploma/Degree; X-ray Cert. or other Certificates*Major Course Of Study*Education #2 add School Name and LocationYears CompletedDiploma/Degree; X-ray Cert. or other CertificatesMajor Course Of StudyEducation #3 add School Name and LocationYears CompletedDiploma/Degree; X-ray Cert. or other CertificatesMajor Course Of StudyEducation #4 add School Name and LocationYears CompletedDiploma/Degree; X-ray Cert. or other CertificatesMajor Course Of StudyReferencesPlease provide three professional references#1Name*Company*Address*Phone#2Name*Company*Address*Phone#3Name*Company*Address*PhoneI 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*Type your full nameToday's Date* Date Format: MM slash DD slash YYYY
