Smallwood Prison Dental Services, Inc

Smallwood Prison Dental Services, Inc.

Application For Employment

Applicant for employment shall be afforded equal opportunity in all aspects of employment without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender or age.

Full legal name ______Home Phone ______

LastFirstMiddle

Address ______Work Phone ______

______

CityStateZip

SS # ______

E-mail Work ______

E-mail Home______

Male Female

Date of Birth______

Place of Birth______

Marital Status______

Emergency Contact Name and Phone Number______

Position Applying For ______

Education

Did you complete High School? Yes No If not, do you have a high school equivalency diploma? Yes No

Circle the number of years of post high school education: 1 2 3 4 5 6 7

Name and Location of InstitutionHrsDegreeMajorMinorDates

ReceivedAttended

______

______

______

If you expect to complete an educational program in the near future, please indicate what type of degree or program and the expected completion date: ______

Experience

Starting with the most recent, describe all paid, military and applicable voluntary experience. Highlight your knowledge, skills and abilities which best demonstrate your qualifications for this position.

May we contact your present employer? Yes No

Job Title ______Duties: ______

Employer ______

Address______

______

Phone______

Supervisor ______Reason for Leaving ______

Salary Start ______Finish ______

Employed From ______To ______Full Time _____ Part-time _____ Hrs per wk ______

Job Title ______Duties: ______

Employer ______

Address______

______

Phone______

Supervisor ______Reason for Leaving ______

Salary Start ______Finish ______

Employed From ______To ______Full Time _____ Part-time _____ Hrs per wk ______

Job Title ______Duties: ______

Employer ______

Address______

______

Phone______

Supervisor ______Reason for Leaving ______

Salary Start ______Finish ______

Employed From ______To ______Full Time _____ Part-time _____ Hrs per wk ______

List any additional information you think would help us evaluate your application, including training, seminars, workshops and special achievements: ______

______

Licensing, certification or other authorization to practice a trade or profession:

TypeLicense NumberGranted By (Licensing Board)

______

______

______

References (minimum of two)

NameAddressPhoneRelationship

______

______

______

Circle the job status you will accept: Full-time Part-time Any

Are you legally eligible for employment in the United States? Yes No

Have you ever been convicted for any violation(s) of law? Yes No

If so, please list:______

______

Date you are available to begin work: ______

Current hourly Salary: ______Please fax your most recent pay stub.

Are you interested in Medical/Health Benefits? Yes No

If Yes: please circle the coverage desired: Empl Only Empl/Children Empl/Spouse Family

Certification

I hereby certify that all entries on these forms are true and complete. I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment with Smallwood Prison Dental Services, Inc. I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that you may contact references, former employers and educational institutions listed regarding this application. I further authorize Smallwood Prison Dental Services, Inc. to rely upon and use, as it seems fit, any information received from such contacts.

Applicant Signature ______Date ______