Online Application

Please provide the following contact information:

First Name			Last Name
Position Applying For	Assistant Hygienist(Lic # Req) Receptionist Office Manager  Hygienist Lic. #   SS #
Street Address			Apt.
City			State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming  Zip
Home Phone			Cell Phone
E-mail
FORMER EMPLOYERS (Most recent first)
Company Name			Phone Number
Employed From			Employed To
City & State			Job Title
Starting Salary			Ending Salary
Responsibilities			Reason for Leaving
Company Name			Phone Number
Employed From			Employed To
City & State			Job Title
Starting Salary			Ending Salary
Responsibilities			Reason for Leaving
Education
High School			Location
Year Graduated	2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940		Diploma:	Yes No
College			Location
Year Graduated			Diploma Received:
Other Trade Schools or Certificates Received:
Total Years Dental Experience			Language: English Spanish Russian German French Japanese Chinese Other:
			(Use Ctrl + click to select more than 1 Language)
Have you had the Hepatitis Vaccine?      Yes No			Employment type: Part-time Full-time
Ever been convicted of a felony?   Yes No			Type of placement:	Permanent Temporary Temp to Perm
Are you eligible to work in the US? Yes No			Are you a US Citizen? Yes No
Availability:	Mon      Tues      Wed      Thu      Fri      Sat      Sun
Do you have reliable transportation? Yes No
How did you hear about us? Careerbuilder.com Long Island Newsday Palm Beach Post LIDHA SCDS NCDS Google Other			If other:
			Office Use Only

Please copy and paste your resume below:  

Temporary & Permanent Staffing Agreement

The following information applies only to the Dental Offices where Elite Dental Staffing Inc. places you for interviews, working interviews or temporary and permanent employment.  There is no fee for registering with our agency.

 Please read the following:          

I (Type Name) agree that all scheduling of temporary placement, permanent placement, interviews and working interviews are conducted only through Elite Dental Staffing Inc. and the Dental Office. If solicited by anyone at a Dental Office for employment it is your responsibility to notify a coordinator at Elite Dental Staffing. 

The following information is your responsibility to keep confidential:

1) Home Phone Number

2)  Cell Phone Number

3) Home Address

4) Email 

The Agency will relinquish the above information to the Dentist if deemed necessary.  Please notify a coordinator if approached by anyone at the dental office requesting the above information.  

Temporary Personnel must notify the Agency of a cancellation 3 hours prior to scheduled work day or a $45.00 fee will be billed.  The fee will be waived if a legitimate doctor’s note is provided within 24 hours.  A $10.00 late fee will accrue for each month past due.  Over Ninety (90) days past due will be subject to collections.   

All Dental Professionals are responsible for informing the Agency if they have accepted a temporary or permanent position.  If you should by-pass the Agency you will be held responsible for the Agency fee.  

If for any reason your position as a dental professional is terminated by Elite Dental Staffing you will receive a certified letter of termination.  You may not solicit any Dentist where we have placed you for work or sent you on an interview for one year after termination. 

I accept the above terms  Yes No

By submitting this form, I certify that the statements made in answers to the questions are true, complete and correct to the best of my knowledge.

10/22/2008