EMPLOYEE APPLICATION

Are you currently employed?yesno

May we contact your present employer?yesno

Have you ever been convicted of any crime? (List all except minor traffic violations such as parking tickets):yesno

Do you have experience working with dental software?yesno

EDUCATION AND TRAINING

WORK EXPERIENCE

Note: Start with the most recent first. (Please attach a resume in addition to filling out the following information):

ADDITIONAL INFORMATION

APPLICATION AGREEMENT

I understand and agree that the information that I have provided on this application is true and complete to the best of my knowledge. Any misrepresentation or omission of any fact in my application, resume, or any other materials, or during any interviews, can be justification for refusal of employment or, if discovered once employed, the termination of my employment with Little Heroes Pediatric Dentistry.

I authorize and request that all of my former employers, including supervisors and managers, and any other individuals I have listed as personal references, furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment, hereby releasing them from any and all liability for damages arising from furnishing the requested information.

All qualified applicants receive consideration for employment without regard to race, color, religion, gender, pregnancy, sexual orientation, age, national origin, disability, marital, veteran, or any other legally protectedstatus.