DENTAL STAFFING APPLICATION Date: Name:

Present Address:

Home Telephone: Cellular:

Social Security Number: D.O.B. / / E-Mail:

Position applied for: Desired Salary:

Are you a Certified Dental Assistant? Yes No (If yes, please provide a copy of your certificate.)

Are you a registered Dental Hygienist? Yes No (If yes, please provide us with a copy of your license.)

Days/Hours you are available to work: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: No Preferences

When are you available to start working? Do you have a Driver’s license?

What means of transportation do you use to commute to work? Who referred you to us?

What areas are you willing to commute to? NYC Queens Bronx Brooklyn Westchester Staten Island Nassau County Suffolk County New Jersey

Last First Middle

( ) ( )WE ARE AVAILABLE TO OUR DOCTORS 24/7. PLEASE KEEP IN MIND THAT WE MAY CONTACT YOU OUTSIDE REGULAR WORKING HOURS

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EDUCATION

WORK EXPERIENCE (Please also submit your resume)

Name of Employer: Address:

City, State, Zip Code:

Phone Number:

Employment Dates: From To Salary: Job Title:

Name of last supervisor: Reason for leaving:

List a brief description of job responsibilities and tasks performed:

Name of Employer: Address:

City, State, Zip Code:

Phone Number:

Employment Dates: From To Salary: Job Title:

Name of last supervisor: Reason for leaving:

List a brief description of job responsibilities and tasks performed:

High School

School NameNumber of yearscompleted Major & Degree

Location(Mailing Address)

College

Bussines orTrade School

ProfessionalSchool

Desired Employment(check all that apply):

Full-Time Part-Time Temporary Permanent

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I, ____________________________________________, agree to let PRECISE Group use my picturefor the agency staffing software/computers/data base for recruiting or staffing purposes. I also agree to submit a written request to PRECISE Group if/when I wish my photo(s) be removed from the agency staffing software/computers/data base for recruiting or staffing purposes.

__________________________________________Employee/Applicant Signature

__________________________________________Date