Employment Application

Personal Information:
Last Name First Name
Address City
State Zip
SS # (Numbers Only) Birthdate (MM/DD/YYYY)      
Cel Phone (Numbers only) Phone Other/Home
E-Mail   US Citizen? (enter Yes or No)
Drivers License Expires (YYYY) 
Have you ever been arrested? Convicted of a Crime?
If YES in Arrested and/or Convicted; Must give all dates and details below.
Answering YES to above questions does not necessarily disqualify you from employment.
Dental Information:
Dental position applying for?

How did you hear about us?
Check if Licensed/Certified in the State of Florida for:
EFDA X-Ray CPR Certified ORTHO Certified
If a Dentist or Hygienist
Florida license number    
Any experience in the specialty field(s)?
Oral Surgery   Ortho   Perio   Endo
Pedo Prostho

   Your Skills:
 X-Rays  Panoramic
Full Mouth
Digital Ceph.
Temporary Crowns Four-Handed Chairside
Preliminary Oral Exam Administering Topical Fluorides
Charting Ultrasonic
Perio Charting Polishing Coronal Crowns
Alginate Impressions

Applying Pit/Fissure Sealants

Oral Health Instructions Placing/Rem. Temp Crowns/Restor.
Applying Topical Anesthetic Assisting in Administration of NO
Suture Removal Placing/Rem. Periodontal Dressing
Apply Cavity Liners/Bases Placing Tofflemire Matrix Retainers
Placing/Rem. Rubber Dam Operate Dryclave
Operate Autoclave Disinfection
OSHA Prescribed Sterilize
Post Operative Instructions
Oral Hygiene Instructions
Soft Tissue Management
Periodontal Training
Filling out Ins. Forms/Filing
Daily Reconciliation 
Daily Deposit
Schedule Appointments 
Computer Literate
Programs Used 

Please check any availability:

I am looking for a:         Permanent      Temporary      Both    

Available Days      Monday  Tuesday  Wednesday  Thursday  Friday   Saturday


Dental experience:

New student 1-5 years  6-12 years  13-20 years  over 20 years  

Please tell us your hourly range : $

Please check areas where you are willing to take a permanent or temporary assignment.

Altamonte Springs Fort Myers/Cape Coral New Port Richey St. Petersburg
Apopka Gainsville Ocala Springhill 
Belleview Groveland Ocoee Sun City Ctr/Apollo Beach
Bradenton Inverness Orlando Tallahassee
Brandon Jacksonville Oveido Tampa
Brooksville Kissimmee Palm Harbor Tarpon Springs
Clearwater Lake City Plant City Venice   
Clermont  Lakeland Port Charlotte Wildwood
Dade City Largo Port Richey Windemere
Daytona Leesburg  Sanford Winter Garden
Englewood Melbourne/Cocoa/ Palm Bay  Sarasota Winter Park / Longwood
Floral City Mount Dora St. Augustine Zephyrhills
West Palm Beach Vero Beach Port St. Lucie Boyton Beach
Jupiter North Carolina Georgia South Carolina

Work Experience:
Name and Address: Job Title:
From: To:  
Supervisor: Phone:
Reason for leaving: Salary:
Name and Address: Job Title:
From: To:
Supervisor: Phone:
Reason for leaving: Salary:
Name and Address: Job Title:
From: To:
Supervisor: Phone:
Reason for leaving: Salary:  

Work References:

Name:   Position:   Phone:

Name:   Position:   Phone:

Name:   Position:   Phone:

This AGREEMENT is made with Dental Staffing Solutions (DSS), Inc. a Florida corporation.

Services To Be Performed. DSS will assist applicant in finding PERMANENT and/or TEMPORARY employment as either a temporary employee or as an independent contractor .
Payment. In consideration of temporary employment or a working interview, the employee or  independent contractor (temp) will be paid an hourly rate for services performed. A daily check will be paid to a temporary upon completion of assignment by Client - Dentist (unless other arrangements have been made between Independent Contractor and Client – Dentist). DSS may choose to employ the temporary worker directly for certain temporary assignments and in that instance the temp will be paid weekly upon submission of a completed time sheet by DM Employer Services, Inc. (DMES)
Sheets. Temporary jobs or working interviews require employer or  independent contractor to submit a time sheet for all services performed for Client-Dentist. Time cards are required to be turned into DSS weekly.
Independent Contractor. The parties intend Applicant to be an Independent Contractor in the performance of these services. Contractor shall have the right to control and determine the method and means of performing the above services; Client - Dentist shall not have the right to control or determine such method or means.
Employee. The parties further agree that if work is accepted as a temporary employee then all rules, policies, and safety precautions set forth by DSS and DMES must be followed. Employee is further required to call our office after each assignment to update their availability. If you do not call our office to update your availability then DSS will consider you have found other means of employment and you will be removed from active status.
Other Clients. Employee or Contractor retains the right to perform services for other Agencies or Client - Dentists not referred by Dental Staffing Solutions.
Employment Agency will
not be responsible (for independent contractor) for income taxes, unemployment insurance, social security taxes, and workers' compensation insurance on independent wages earned. Temporary employees will receive a net paycheck less required taxes and year end w-2 form.

Verification of Licensure, References and/or Job and Criminal History. Dental Staffing Solutions has permission to verify the information entered on my employment application. I attest that all information I entered on my employment application is true and correct to the best of my knowledge.  I hereby release DSS and DMES, its agents, officials and representatives both individually and collectively, from any and all liability for any damages that may arise from this authorization and request for release of information.

I further understand that Dental Staffing Solutions acting on my behalf is providing a service to me and is due a finders fee paid by their Client - Dentists. I acknowledge I am responsible for the finders fee if I
do not inform Dental Staffing Solutions within 24 hours of a job offer whether temporary or permanent. I further understand I will be responsible for all court and/or attorney’s fee necessary to collect a finders fee from me if found responsible for violating this agreement.

By electronically submitting this contract, you are accepting our terms and conditions. Your application will be processed and you will be referred for employment. If you choose to decline at this time, you may e-mail or call one of our placement coordinators at (727)547-8233 or (813)877-8233 with any questions about the services we provide.

By typing my name below, I affirm that all  information submitted on this application is true and correct and I accept the Employment Agreement stated above.

Employee's electronic signature   Date