Employment Application with Ortho South

Full Name

Email

Phone

Address

How long have you lived in this area?

Have you applied to Ortho South before and if so, when?

What position are you applying for?

What type of employment are you seeking?

What days of the week will you NOT be able to work?

How many days in the last year have you been off work due to an illness?

If you have children, do you have someone that can help you when they are sick?

Will transportation to work at this office be a problem for you?

If offered employment, how soon would you be able to start?

Can your vacation be arranged almost any time and if not, when?

Highest level of education received?

Name of High School

High School Address

Number of Years Completed at High School

Date Last Attended High School

Did you earn a High School diploma?

Name of Trade/Tech School

Trade/Tech School Address

Number of Years Completed

Date Last Attended Trade/Tech School

Did you earn a certificate, diploma or degree?

What was trade/tech field did you study?

Name of College or University

College or University Address

Number of Years Completed

Date Last Attended College

Did you earn a degree?

What was your field of study?

Do you have typing skills?

How many words per minute can you type?

Do you have computer skills?

List software you’re experienced with.

Have you handled group insurance?

Have you handled PPO or HMO policies?

Have you used dictation equipment?

Have you replaced or removed O-ties?

Have you changed arch wires?

Have you poured models?

Have you taken impressions?

Have you fit ortho bands?

Have you given plaque control instructions?

Are you familiar with bonding procedures?

Do you have knowledge of ortho instruments?

List any other skills you possess that might be relevant.

Last Employer Name

Last Employer Address

Last Employer Phone

Last Direct Supervisor Name

Last Supervisor Job Title

Your Title with Last Employer

Your Responsibilities with Last Employer

Date Started - Date Ended | Last Employer

Pay Rate with Last Employer

Reason for leaving Last Employer

Previous Employer Name

Previous Employer Address

Previous Employer Phone

Previous Direct Supervisor

Previous Supervisor Job Title

Your Title with Previous Employer

Your Responsibilities with Previous Employer

Date Started - Date Ended | Previous Employer

Pay Rate with Previous Empoyer

Reason for Leaving Previous Employer

May we contact all the preceding employers and if not, which one(s) do you wish we not contact?

If you have any periods of unemployment, please list dates and reasons.

How do you feel about working with children?

What 3 things are most important to you?

What is the condition of your teeth?

How is your health?

Do you have any health limitations and if so, what are they?

What unique qualities will you bring to the office?

How do you feel about continuing education, and attending seminars off of normal business hours?

Do you feel you are average?

Professional Reference #1 - Name

Professional Reference #1 - Phone

Professional Reference #1 - Address

Professional Reference #2 - Name

Professional Reference #2 - Phone

Professional Reference #2 - Address

Professional Reference #3 - Name

Professional Reference #3 - Phone

Professional Reference #3 - Address

What are your short/long term employment goals?

What is the purpose of an orthodontic practice?

What qualities do you possess that make you stand apart from others?

What do you feel you would contribute to the growth of the practice?

In what ways do you work on improving yourself and how do you feel about continuing to be better?

Please upload a copy of your resume.

Upload File

Acknowledgement

By clicking this, I understand that if I am employed and any statement herein is not true, I may be released immediately. I will be paid only through the day of release and the employer may cancel any vacation, holiday or sick leave benefits that may have accrued to me based on my employment. I have had an opportunity to see the posted notices containing the provisions of the ADA.

EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION

205-624-0030

2705 Pelham Parkway, #200

Pelham, AL 35124

8535 US-31

Calera, AL 35040