Dental Hygienist

Fields marked with an asterisk (*) must be filled out before submitting.

DEPARTMENT
Rural Health Clinic

EMPLOYMENT TYPE
Full-time

EDUCATION/EXPERIENCE

• Dental Hygienist certificate, associate degree, or a baccalaureate degree in dental hygiene

• One year of dental experience

CERTIFICATES, LICENSES, REGISTRATIONS

• Current CA dental hygienist license

• Current x-ray license

• Current CPR certificate

Name *

First

Last

Other name under which you have been educated or employed.

First

Last

Address *

Address Line 1

Address Line 2

City

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Zip Code

Phone *

Email *

Available To Work *

• Full Time
• Part Time
• Per Diem
• Temporary
• Days
• Nights

If you are under 18 years of age, can you produce a work permit if hired? *

• Yes
• No

Can you, after employment, submit verification of your legal right to work in the United States? *

• Yes
• No

If employed in the position for which you have applied, would you be in a supervisory, subordinate, or co-worker (i.e. within the same department) relationship to any relative or member of your household? *

• Yes
• No

If yes, please specify

EDUCATION

Highest grade completed

• 9
• 10
• 11
• 12

College or University (Include Name, Location, Major Subjects, and Degrees Conferred)

Graduate School (Include Name, Location, Major Subjects, and Degrees Conferred)

Other – Military, Apprenticeship, Vocational (Include Name, Location, Major Subjects, and Degrees Conferred)

LICENSES AND CERTIFICATIONS

Are you registered or certified by any professional job related organization, or do you hold a professional or occupational license in the State of California?

• Yes
• No

If yes, please specify

Registration or License Details (Include Number, Expiration Date, and Type)

Do you hold or have you ever held a certification, professional or occupational license in a state other than California?

• Yes
• No

If yes, which state?

Registration or License Details (Include Number, Expiration Date, and Type)

Please upload any certificates or licenses that may apply to this position.

Languages you read, speak or write, other than English, if relevant to the job in which you are applying (Indicate if you can Speak/Read/Write)

Source of Referral

• Self
• Newspaper
• School
• State Employment Office
• Community Agency
• Recruited By The Hospital

EMPLOYMENT HISTORY

EMPLOYER #1

Address

Telephone Number / Ext

Your Supervisor

What were your principal duties and title?

Started Work (Month/Year)

Left Work (Month/Year)

Reason for leaving?

May we contact?

• Yes
• No

EMPLOYER #2

Address

Telephone Number / Ext

Your Supervisor

What were your principal duties and title?

Started Work (Month/Year)

Left Work (Month/Year)

Reason for leaving?

May we contact?

• Yes
• No

EMPLOYER #3

Address

Telephone Number / Ext

Your Supervisor

What were your principal duties and title?

Started Work (Month/Year)

Left Work (Month/Year)

Reason for leaving?

May we contact?

• Yes
• No

EMPLOYER #4

Address

Telephone Number / Ext

Your Supervisor

What were your principal duties and title?

Started Work (Month/Year)

Left Work (Month/Year)

Reason for leaving?

May we contact?

• Yes
• No

EMPLOYER #5

Address

Telephone Number / Ext

Your Supervisor

What were your principal duties and title?

Started Work (Month/Year)

Left Work (Month/Year)

Reason for leaving?

May we contact?

• Yes
• No

In addition to the information already provided, list any volunteer activities, training or other experience that you feels qualifies you for the position for which you have applied: You may omit those which may indicate race, age, sex, religion, color, national origin or sexual orientation.

SIGNATURE - By typing my name I am offering my electronic signature and acknowledge that I understand and agree to all of the statement below *

Name

Submit Your Application

I hereby certify that I have been informed of the duties of the position that I am applying for and that the information of this application is correct and complete to the best of my knowledge. I agree to have any of the statements checked by the Mountains Community Hospital unless I have indicated to the contrary. I understand and agree that, if offered a position, I will be required to take and pass a physical examination including drug testing before I will be allowed to commence work. Further I understand that falsification or omission of any material information on this application may be considered sufficient cause for immediate termination. I agree that, if employed, I will abide by and observe all policies, procedures, rules and regulations established by Mountains Community Hospital and understand that my employment is at will, if hired.