Wufoo
trentonsmiles.com - Employee Application
JSP Dental
254 West Rd
Trenton MI 48183
734-676-1333
It is the policy of JSP Dental to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability, or verteran status.
I certify that the information provided on this application is truthful and accurate. I understand providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.
I authorize JSP Dental to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate information regarding my previous employment and education.
If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of JSP Dental, the employment relationship will be "at will." In other words, the relationship will be entirely voluntary in nature and either I or my employer will be able to terminate the employment relationship at any time and without cause. With appropriate notice, I have the full and complete discretion to end the employment relationship when I choose and for reasons of my choice. Similarly, JSPDental will have the same right. Moreover, no agent, representative, or employee of JSP Dental, except in a specific written contract of employment signed on behalf of the organization by its owners, has the power to alter or vary the voluntary nature of the employment relationship.
I have read the above certification and I understand and agree to its terms. ( You will Docusign this form once you submit document- another screen will appear)
Name
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Last
Address
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Street Address
Address Line 2
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Email- type accurately please
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Cell Phone Number
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Driver's License Number
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I am applying for:
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Hygienist
Dental Assistant
Front Desk Personnel
Dentist
I will be available to start on:
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MM
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DD
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YYYY
Reference Number 1
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First
Last
Reference Number One-Phone Number
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Reference Number 2
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First
Last
Reference number 2 -Phone Number
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Education, Training, Degrees- Name and Dates
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Goals, Philosphy, Your attitude in a work environment
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Availability- do you desire full or part time? If part-time, when are you available?
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Emergency Contact
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First
Last
Phone Number
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Relationship of Emergency contact
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Who Referred You to Our Company?
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Have you previously applied to our company?
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Are you at least 18 years old?
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Yes
No
Are you willing to work evenings and /or Saturdays?
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Yes
No
How will. you get to work?
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If hired, are you able to submit proof that you are legally eligible for employment in the US?
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Yes
No
Are. you able to perform the essential functions of the job position you seek with or without reasonable accommodations?
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Yes
No
Any Accommodations Requested
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Any additional information. you feel we should know:
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Check all that apply- Do you have a working knowledge of:
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HIPAA
CPR
Customer Service
Dental Terminology and Proceedures
Check all that apply- Do you have a working knowledge of:
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Dentrix
Microsoft Word
Excel
Check all that apply- Do you have:
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Hygiene License
Dental License
Registered Dental Assistant License
Dental Assisting Experience, but no license
Prior Front desk Experience
Telephone Skills Training
List in Chronological order starting with most recent: employer, dates employed, reason for leaving, and name and contact information for last ten years.
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