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Dental Hygienist
DATE OF APPLICATION
POSITION APPLIED FOR
RESUME
HAVE YOUR PRIVILEGES AT ANY INSTITUTION BEEN LIMITED, RESTRICTED OR REVOKED?
YES
NO
HAS YOUR NARCOTICS REGISTRATION BEEN SUSPENDED OR REVOKED?
YES
NO
HAVE YOU EVER BEEN INVESTIGATED OR CENSURED FOR VIOLATION OF A PATIENT RIGHTS (HIPPA)?
YES
NO
HAVE YOU BEEN DENIED MEMBERSHIP, RENEWAL OR HAS DISCIPLINARY ACTION BEEN INSTITUTED AGAINST YOU IN ANY PROFESSIONAL ORGANIZATION (I.E. MEDICAL, DENTAL OR HYGIENE)?
YES
NO
HAVE YOU BEEN A DEFENDANT OR A SUBJECT OF MALPRACTICE ACTION?
YES
NO
DO YOU HAVE, OR ARE YOU SUBJECT TO ANY PENDING ACTIONS BY THE NEW YORK STATE DEPARTMENT OF EDUCATION, DEPARTMENT OF PROFESSIONAL DISCIPLINE OR ANY OTHER STATE IN WHICH YOU MAY HOLD (OR HAVE HELD) A PROFESSIONAL LICENSE?
YES
NO
HAVE YOU EVER BEEN DENIED OR HAD YOU MEDICAL MALPRACTICE REVOKED, NON-RENEWED, LIMITED OR TERMINATED
YES
NO
HAVE YOU EVER BEEN SUSPENDED, SANCTIONED OR OTHERWISE RESTRICTED FROM PARTICIPATING IN ANY PRIVATE, FEDERAL OR STATE HEALTH INSURANCE PROGRAM?
YES
NO
HAVE YOU EVER BEEN INVESTIGATED OR CENSURED FOR VIOLATION OF PATIENT'S RIGHTS?
YES
NO
DO YOU HAVE ANY IMPAIRMENT (MENTAL OR PHYSICAL) THAT MAY INTERFERE WITH THE PERFORMANCE OF YOUR DUTIES?
YES
NO
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
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