Full Name:

Telephone (home):

Address (number, street, city, state, zip):

Telephone (cell):

Do you have the legal right to work in the United States? (select one)YesNo

E-mail address:

Work Permit - Type of verification (If you are a U.S. citizen, leave blank)

If you are bi-lingual, what languages do you

Speak

Read

Write

Have you had experience in the following:

If checked yes, what is your skill level?

Typing on a Computer

Experience working in sales

Computerized Bookkeeping

Microsoft Word, Excel, Powerpoint

E-mail / Social Media

Account Collections

Dental Marketing

Ordering Dental Supplies

Patient Recare For Hygiene

Treatment Plan Presentations

Fee Presentations

Dental Terminology

Insurance Processing

Appointment Scheduling (On phone and in person)

Electronic Dental Charting

Digital X-Rays (take & enter into software)

Intraoral Cameras

Oral Hygiene Instructions

Promote and Sell Dentistry To Patients

CPR Training

Procedure tray setups

Assisting the dentist during dental procedures

Take dental impressions / pour up and trim models

Place dental sealants

Polish the coronal portion of teeth

Administer local anesthesia (hygienists/dentists)

Administer nitrous oxide (hygienists/dentists)

Fabricate & cement temporary crowns

Fabricate whitening trays / mouthguards

Open Dental Software

Patterson Eaglesoft Dental Software

Dentrix Dental Software

Post graduate continuing education courses / seminars taken in the last 2 years:

Are all certifications current?

YesNo

If hired, do you agree to give us a copy of all of your current certifications?

YesNo

Do you have any physical condition which could (1) limit your ability to perform the job applied for, (2) be aggravated by the job you have applied for?

YesNo

If yes, explain:

Check times willing to work:

Days

Evening

Weekends

Number of days per week

Full-time

Part-time

Hours per week

Check the day(s) of the week you will NOT be able to work.

Can your future vacations be arranged at office convenience?

YesNo

If no, explain:

If offered employment, when can you start?

Salary requirement:

Fringe benefits requirements:

Have you ever been convicted of a felony?

*A conviction record will not necessarily be a bar to employment

List present or most recent position first. Cover last 7 years, including periods of self-employment, or
unemployment. Fill in all information – DO NOT SUBSTITUTE WITH A RESUME

May we contact your current employer?

YesNo

Explain any significant gaps in employment history during the past 7 years:

APPLICANT CERTIFICATION THAT INFORMATION IS ACCURATE AND COMPLETE: I attest that the
information provided on this application (and accompanying resume if applicable) is true and complete. I understand that any false information, misrepresentation, or omission – oral or written –
may disqualify me from further consideration for employment and, if hired, may result in discipline or dismissal if discovered at a later date.

APPLICANT’S CONSENT TO VERIFY INFORMATION AND RELEASE: I authorize Caring Smiles Family
Dentistry to investigate my employment history and all statements contained in this application,
including records of any former employers and other references or sources concerning me. I authorize
all references and sources to provide this information to Caring Smiles Family Dentistry and release
such references and sources from liability for doing so. I waive my right to any written notice of the release of such records that may be required by state or federal law.

APPLICANT’S CONSENT TO INVESTIGATIVE CONSUMER REPORT: I understand that due to the
nature of the jobs at Caring Smiles Family Dentistry, an investigative consumer report may be made
whereby information is obtained through interviews with various third parties. These inquires may
include information as to criminal, credit, driving record, character, general reputation, personal
characteristics and mode of living, whichever may be applicable. I understand I have the right to make a written request to Caring Smiles Family Dentistry, within a reasonable period of time for additional information concerning the nature and scope of any investigation conducted. I also acknowledge receipt of the previous statement regarding investigative consumer reports.

EMPLOYMENT POLICIES: I understand that this application will remain active for consideration for six (6) months (180 days). If at the conclusion of this period, I want Caring Smiles Family Dentistry to continue to consider me for employment, I must reapply. I understand that as a condition of employment I agree to comply with Caring Smiles Family Dentistry’s employee policies and work rules, including but not limited to its confidentiality and conflict of interest policies.

EMPLOYMENT-AT-WILL: I understand that the Caring Smiles Family Dentistry is an “at-will”
employer. As such, employment with Caring Smiles Family Dentistry may be terminated at the will of
either party, with or without cause, and without prior notice. I understand that no supervisor or other representative of Caring Smiles Family Dentistry, except the Owners and only when in writing (signed and dated by both parties), can enter into an employment contract, either written or verbal.

JOB FUNCTIONS: I attest that I can perform the essential functions of the job, with or without reasonable accommodation. I understand that under Michigan law, if I am a qualified individual who is disabled and requires an accommodation, I understand that it is my responsibility to request an accommodation within 182 days after the date I knew or reasonably should have known that an accommodation was needed.

STATUTE OF LIMITATIONS: I understand that as a condition of employment I agree not to commence any action or suit relating to my employment relationship with Caring Smiles Family Dentistry beyond six (6) months (180 calendar days) after the date of the event or the date of termination of employment. I also agree to waive any statute of limitation to the contrary.

I understand that my employment will not be considered unless this application is completed in its entirety.

Signature of Applicant

Date