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PO Box 630812 Aventura FL 33163 THE DENTAL GENIE STAFFING SERVICES Phone 305. 816. 0990 Cell 305. 335. 0238 Fax 305. 816. 0096 diana thedentalgenie. com www. thedentalgenie. com APPLICATION FOR EMPLOYMENT FIRST NAME LAST NAME ADDRESS CITY STATE HOME PHONE ZIP MOBILE PHONE E-MAIL ADDRESS DATE OF BIRTH SOCIAL SECURITY HYGIENE LICENSE IS YOUR LICENSE CURRENT YES NO WHERE ARE YOU CURRENTLY EMPLOYED WHAT IS YOUR CURRENT PAY RATE DO YOU OWN A VEHICLE HOW FAR ARE YOU WILLING TO TRAVEL YEAR MAKE MODEL WHO DO WE NOTIFY IN CASE OF EMERGENCY NAME PHONE NUMBER EMPLOYMENT INFORMATION Please select the position you are applying for FRONT OFFICE DENTAL HYGIENIST DENTAL ASSISTANT FULL TIME PART TIME TEMPORARY FOR PART TIME WHAT DAYS ARE YOU AVAILABLE MON TUES WED THU FRI SAT SUN continued on next page Dental Hygienists Dental Assistants Temps-to-Hire Front Office Permanent Placement Temps Diana Galvis R*D. H. PLEASE LIST YOUR WORK EXPERIENCE List all with most recent first PLACE OF EMPLOYMENT DATES TO FROM IMMEDIATE SUPERVISOR NAME NUMBER JOB POSITION DUTIES SCHOOL DEGREE/CERTIFICATION PLEASE ATTACH YOUR RESUME On the next page please paste your text resume into the blank eld. If your resume is more than one page do not worry as the text will scroll down the page. Terms and Conditions I agree that the above information is true and correct. I also agree when working through The Dental Genie Inc* I will report any additional days worked for any doctor. I agree that all scheduling of temporary placement permanent placement interviews and working interviews are conducted only through The Dental Genie Inc* and the Dental Office. If solicited by anyone at a Dental office for employment it is your responsibility to notify a coordinator at The Dental Genie Inc* Failure to do this will preclude The Dental Genie Inc* from using me in the future and will also carry a fine. Further I recognize that it is also my responsibility to report permanent positions that have been offered to me. I also understand that personnel provided by The Dental Genie shall be employees of the doctor and not of The Dental Genie Inc* I accept the above terms YES Have you ever been convicted of a felony If yes - please explain Are you a US Citizen If No please answer Do you have the right to work in the United States signature By submitting this form I certify that the statements made in answers to the questions are true complete and correct to the best of my knowledge. 0238 Fax 305. 816. 0096 diana thedentalgenie. com www. thedentalgenie. com APPLICATION FOR EMPLOYMENT FIRST NAME LAST NAME ADDRESS CITY STATE HOME PHONE ZIP MOBILE PHONE E-MAIL ADDRESS DATE OF BIRTH SOCIAL SECURITY HYGIENE LICENSE IS YOUR LICENSE CURRENT YES NO WHERE ARE YOU CURRENTLY EMPLOYED WHAT IS YOUR CURRENT PAY RATE DO YOU OWN A VEHICLE HOW FAR ARE YOU WILLING TO TRAVEL YEAR MAKE MODEL WHO DO WE NOTIFY IN CASE OF EMERGENCY NAME PHONE NUMBER EMPLOYMENT INFORMATION Please select the position you are applying for FRONT OFFICE DENTAL HYGIENIST DENTAL ASSISTANT FULL TIME PART TIME TEMPORARY FOR PART TIME WHAT DAYS ARE YOU AVAILABLE MON TUES WED THU FRI SAT SUN continued on next page Dental Hygienists Dental Assistants Temps-to-Hire Front Office Permanent Placement Temps Diana Galvis R*D. H. PLEASE LIST YOUR WORK EXPERIENCE List all with most recent first PLACE OF EMPLOYMENT DATES TO FROM IMMEDIATE SUPERVISOR NAME NUMBER JOB POSITION DUTIES SCHOOL DEGREE/CERTIFICATION PLEASE ATTACH YOUR RESUME On the next page please paste your text resume into the blank eld.