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Dental Assistant

DATE OF APPLICATION

POSITION APPLIED FOR

RESUME

HAVE YOU EVER BEEN TERMINATED OR ASKED TO RESIGN FROM ANY POSITION?

HAVE YOU EVER VIOLATED ANY STATES, US JURISDICTION,OR FEDERAL LAW REGULATING THE PRACTICE OF A HEALTH CARE PROFESSIONAL?

HAVE YOU EVER BEEN INVESTIGATED OR CENSURED FOR VIOLATION OF A PATIENT RIGHTS (HIPPA)?

HAVE YOU EVER HAD A CERTIFICATE, LICENSE, REGISTRATION,OR OTHER PRIVILEGE TO PRACTICE A HEALTH CARE PROFESSION DENIED, REVOKED,SUSPENDED, RESTRICTED,REPRIMANDED, CENSURED OR PLACED ON PROBATION BY A STATE OR US JURISDICTION, FEDERAL, OR FOREIGN AUTHORITY, OR HAVE YOU EVER SURRENDERED SUCH A CREDENTIAL TO AVOID OR IN CONNECTION WITH ACTION BY SUCH AUTHORITY?

The applicant understands that this application and other company documents are not a contract nor constitute employment. The applicant understands that if s/he is hired they will be required to produce proof that they have a legal right to work in the USA in accordance with the IRCA of 1986. The applicant agrees to inquiry of former employers or other sources as to experience, character and/or reason for termination or leave, and authorize companies to release such information without liability. The applicant understands that as part of employment they are required to have a physical examination and will provide needed physical examination(s) and any future physical examination as required by the employer. The applicant understands that as part of employment process they may be required to undergo a criminal background check. If employed, the applicant agrees to abide by the policies established by DentServ Dental Services, PC. The applicant hereby understands and agrees that any misrepresentation of information provided may be cause for dismissal.

I understand and agree that l, as an applicant, have the burden of producing adequate information for the proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubts about such qualifications. I agree that further verification of my identify may be obtained if deemed necessary by Dentserv. I will not participate in any form of illegal fee splitting.*

Yes, I agree

l have read, understand, and agree to the above as part of job selection review and process.*

Yes, I agree

I affirm and certify that the information provided on this application is true and complete. I understand that false information or omission of facts may disqualify me and/or may result in termination if discovered at a later date.*

Yes, I agree

SIGNATURE

DATE

New York State's Leading On-Site Dental Provider

info@dentserv.com | +1(914) 738-1144

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Dental Assistant