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Julie Staggers Orthodontics

3052 Valley Ave. #100

Winchester, VA 22601

JOB APPLICATION

Name*

Phone*

Address*

What position are you applying for*

Dental Assistant

Receptionist

Sterilization Assistant

Others

Education: Please enter the high school and college attended AND THE YEARS of graduations.*

Please enter all jobs held in the past 7 years and the time period employed. If you were unemployed, please list unemployed.*

Please list any skills or experience that you have working in dentistry. (Taking radiographs, assisting, taking impressions, digital scanning, etc.)

Please list any other employment skills that you have. (Typing or word processing, customer service, scheduling, money collection, inventory control, personal management, etc.)

What are you looking for in a job? (Describe your dream job)*

How many hours per week would you like to work?*

What are your expected hourly starting salary and benefits? Do not put negotiable.*

What are your expected salary and benefits after one year of employment? Do not put negotiable.*

What type of employment are you looking for?*

Have you ever been fired from a job?*

If yes, which job?

Have you ever been laid off from a job?*

If Yes, which job?

Have you every quit a job without giving your employer at least two week notice?*

If Yes, which job?

Have you ever been charged or convicted of a crime?*

Yes, Please explain in box below

Are you willing to spend time outside of work hours learning new skills?*

Yes

How quickly do you learn new material?*

A comprehensive dental assistant training program is available. Some of the material is written, some of the material is on video and some of the material is online. Are you interested in completing the dental assistant training program?*

Yes

I don't know

No, I am looking for a short-term job

No, I am applying for a receptionist position

How do you spend your free time when you are not working? Hobbies?*

Do you work well with others?*

Yes

It depends on the coworker

I don't know

No, I prefer to work alone

How many times per month do you miss work due to family obigations?*

Do you like a fast pace work environment?*

Yes

I don't know

Maybe

Do you want to work with coworkers of all ages?*

Yes, I like variety

I don't know

No, I don't like coworkers who are: (fill in: older, younger, millenials, lazy, negative, arrogant, etc.)

Do you enjoy working with children*

Yes

I don't know

Do you value advanced job training provided to you at no cost?*

Yes

I don't know

How soon would you like to start this job?*

Due to HIPPA Privacy Regulations, the office has a policy that you can not have a cellphone on you when providing patient care. Cell phones can only be used during break times in the staff lounge. The office computers may not be used for personal emails or social media use. Are you willing to abide by this policy? *

Yes

Are you a job hopper?

No, I am looking for a long-term position

Yes, I am looking for a short-term temporary position

Yes, I like the variety of switching jobs frequently

My job pays for my life. I switch jobs as needed to fit my lifestyle

I don't know

In person interviews and office tours are conducted for prospective employees. Are you interested in an in person interview?*

Yes

I don't know

No, just call me on the phone

Email or text me

Are you attending college now?

No and I have no plan to

No, but I plan to attend college within the next 12 months

Yes and am pursuing a non-dental degree

Yes and am planning to attend a dental hygiene program

Is there any additional information that you would like to provide?

Office Work Attire Policies

Are You Willing To Abide By Our Office Attire Policies?*

Yes

I don't know

IMPORTANT

Our office will take the time to train you and pay the training costs for a career in dentistry. Please do not waste our training time and money if you are not serious about long term employment. We will treat you will respect as an employee and will provide accurate information as to the employment opportunity and its benefits. Please show us the same level of respect by being honest about your employment plans, the information that you provide and your employment expectations. Thank you!

Questons with a * at the end must be answered in order to submit the application.