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HealthStaff, 14109 Overbrook St., Ste. E, Leawood, Kansas 66224, Phone: 913-402-4334, Fax: 913-402-4554
 
HealthStaff Online Application
* required field

How did you hear about us? Referral
Newspaper
Other:
Personal Information
Name: *
Address: *
City: *
State: *
Zip code: *
Home phone: *
Cell phone:
Email address: *
What position(s) are you applying for (check all that apply)? Hygienist
Assistant
Front Office
Office Manager
Dentist
If you are a dental hygienist, what certifications do you have in Missouri or Kansas (check all that apply)? CPR
KS Local Anesthesia
MO Local Anesthesia
If you are a dental assistant, what certifications do you have (check all that apply)? Digital Radiographs
Expanded Functions
CPR
Have you been named in a medical professional liability suit within the last five years? No
Yes
If yes, please explain:
Have you ever been convicted of a felony? No
Yes
Licensure (Hygienists Only)
License #: State: Expiration:
Inactive
Active
License #: State: Expiration:
Inactive
Active
License #: State: Expiration:
Inactive
Active
License #: State: Expiration:
Inactive
Active
Have you ever had disciplinary action taken against any of your licenses? No
Yes
If yes, please explain:
Experience
How much experience do you have in the dental industry? New student
1-5 years
6-12 years
13-20 years
Over 20 years
Specialty Experience
What specialties do you have experience with (check all that apply)? Perio
Pedo
Prosth
Oral Surg
Ortho
Education
High School: Name and location
Graduated
Did Not Graduate
College: Name and location
Graduated
Did Not Graduate
Advanced: Name and location
Graduated
Did Not Graduate
Former Employers
Name of Present or Last Employer:
Address
City
State
Zip code:
Start Date:
End Date:
Job Title:
Starting Weekly Salary:
Final Weekly Salary:
Name of Supervisor:
Title:
Phone Number:
May we contact your supervisor? Yes
No
Description of Work:
Reason for Leaving:
Name of Previous Employer:
Address
City
State
Zip code:
Start Date:
End Date:
Job Title:
Starting Weekly Salary:
Final Weekly Salary:
Name of Supervisor:
Title:
Phone Number:
May we contact your supervisor? Yes
No
Description of Work:
Reason for Leaving:
Authorization
I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

I have read and agree to the conditions above: