HealthStaff - Staff Login

HealthStaff, 12980 Foster, Ste. 120, Overland Park, KS 66213, Phone: 913-402-4334, Fax: 913-402-4554

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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: