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Smile Staffing Agency, LLC
Personal Information
First Name
*
Last Name
*
Address 1
*
Address 2
City
*
State
*
Zip Code
*
Phone
*
Email Address
*
Position Applying For
*
Dental Hygienist
Dental Assistant
Office Personnel
Office Manager
Are you legally authorized to work in the United States?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please explain.
Availability
Days Available
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Employment History
Employer 1
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager
Reason for Leaving
May we contact?
*
Yes
No
Phone Number
Employer 2
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager
Reason for Leaving
May we contact?
*
Yes
No
Phone Number
Employer 3
Company Name
Address
Phone
Start Date
+
End Date
+
Position
Salary
Supervisor/Manager
Reason for Leaving
May we contact?
*
Yes
No
Phone Number
References
Reference 1
Name
Title
Email Address
Phone
Reference 2
Name
Title
Email Address
Phone
Reference 3
Name
Title
Email Address
Phone
Additional Skills
List any additional skills that you would like to mention, i.e. dental software, four handed dentistry, scaling and root planing, etc.
Please upload photo of proper licenses and certificates
*
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