EMPLOYMENT APPLICATION Vista Hills Family Dental *713 Weston Brent Lane

El Paso, Texas 79935

Please print your responses using blue or blank ink. The employer is sometimes referred to below as “Company”.

Please read the attached job description for the position being applied for.

IDENTIFICATION:

Date:

Full Name:

Social Security No.:

Present Address:

[Street] [City] [State] [Zip Code]

Phone No.:

Referred By:

EMPLOYMENT APPLIED FOR:

Position:

Salary Desired:

Are you applying for: Full Time Part Time Temporary (includes holiday or summer employment)

Days and hours available to work:

Will you be available to work: Weekends? Yes Overtime as necessary? Yes

No No

Date you are able to start:

Are you currently employed? Yes No

May we request information from your past and/or present employer? Yes No

Have you ever applied for work with this company before? Yes No

If so, when?

Vista Hills Family Dental is an Equal Opportunity Employer. This company does not and will not discriminate in employment and personnel practices on the basis of race, sex, age, handicap, religion, national origin or any other basis prohibited by applicable law. Hiring, transferring and promotion practices are performed without regard to the above listed items.

PERSONAL INFORMATION:

EDUCATION:

Name & Location of Institution

Years

Attended

Did you Graduate?

Name of Degree or Diploma

Area of Study

Grammar School

Yes

No

High School

Yes

No

College or University

Yes

No

Trade, Vocational, Business or Correspondence School

Yes

No

GENERAL:

Do you possess any other knowledge, training, and/or skills that qualify you for the position in which you are applying for? Yes No

If so, please specify:

U.S. Military Service: Rank:

Are you 18 years of age or older? Yes (Persons under 18 must verify they are of minimum legal age to be hired)

No

If the Company hires you, will you be able to document your U.S. Citizenship or prove your legal right to live and work in the U.S.? Yes No

Have you been convicted at any time of a felony or serious criminal misdemeanor? Yes No

(NOTE: you do not have to list convictions for marijuana offenses more than two years old.)

If yes, specify the crime(s), the date and location of the conviction and the current status of the case:

(NOTE: An applicant will not be turned down for employment solely because he/she has been convicted of a crime. The particular crime, the date of conviction, the circumstances of the crime and the relation of the nature of the crime to the position being applied for can be considered by the Company in making the final hiring decision.)

If you are applying for a professional position:

Do you have a license or certificate for the position desired? Yes No

License/Certificate Type:

Number:

Issuing State:

Issue Date:

Has the license or certificate been suspended or revoked at any time? Yes No

If yes, please specify the grounds for suspension/revocation, date of action and date of reinstatement:

I have read and I understand the attached job description for the position being applied for

Are you able to carry out the essential aspects of the position you are applying for? Yes No

If not, please state the job functions that cannot be carried out:

(NOTE: This Company complies with the Federal Americans with Disabilities Act and Title VII of the Civil Rights Act of 1964 and will thus strive to implement measures needed to accommodate qualified applicants and employees to handle essential functions of a job. Hiring may be conditioned on passing a medical examination and/or tests of skill and dexterity.)

HISTORY OF EMPLOYMENT:

[List below your last four employers, starting with the last one first]

Date

[Month & Year]

Employer Name, Address and Phone No.

Type of Business

Salary

Position(s)

Held

Reason for Leaving

From:

Supervisor:

Start

$

End

$

To:

From:

Supervisor:

Start

$

End

$

To:

From:

Supervisor:

Start

$

End

$

To:

Please explain any gap in employment history:

REFERENCES:

Please supply three people not related to you who can provide first-hand information of your work skills and performance within the past four years.

Name

Address and Telephone No.

Business

Occupation

Years Known

Please fully read and understand the text below, initial separately at each paragraph; and date and sign at the bottom:

1. I acknowledge and attest that I have completed this application for employment as well as any and all other related or supplemental documents personally and that all the answers supplied in this application and the other documents are complete and accurate. I also acknowledge and attest that I have not intentionally omitted or failed to disclose any data that may reduce my prospects for employment with this Company. I further acknowledge, attest and agree that any falsification or omission of, or failure to disclose, such relevant information shall cause the Company, on discovery of the problem, to reject the application or, if I am employed, to immediately terminate employment.

2. I authorize the Company to research and investigate, through the references I have supplied and any other lawful channel, my employment history, education, skills and any other matter related to my qualifications for the position applied for. I similarly authorize the references I have supplied to disclose to the Company -- and, unless otherwise required by law, without any notice to me of such disclosure—any and all reports, transcripts, letters and other records and documents related to my past work, education and any other matter related to my qualifications for employment. Further, I hereby release the Company, all my past employers, all my past educational institutions and all other individuals, corporations, partnerships and organizations from any and all actions, suits, claims, demands, liabilities, damages, costs and expenses, including reasonable attorney fees arising from or in any way related to such research, investigation and/or disclosure. This authorization includes my permission for the Company to request and obtain any “consumer report”, “investigative consumer report”, or any other report or compilation regarding my character, general reputation, personal characteristics, financial history, and/or mode of living as may covered by the Federal Fair Credit Reporting Act (FCRA) or any other federal, state, or local law or regulation. I agree to execute any other document reasonably necessary to enable the Company to accomplish the aims of this paragraph.

3. Having read and understood the attached job description, I acknowledge and agree that in order to enable the Company to determine whether I possess the skills and other personal qualities necessary to qualify for the position I am applying for, the Company may engage in a testing and interview process. The tests may include but are not limited to those that measure intelligence, aptitude and personality traits required to meet the requirements of the position, including but not limited to meeting the Company’s standards for performance, interpersonal relations and competence on the job. Accordingly, I hereby release the Company and any and all Company employees, representatives, associated testing services and any and all other individuals, corporations, partnerships and organizations from any and all actions, suits, claims, demands, liabilities, damages, costs and expenses, including reasonable attorney fees, arising from or in any way related to such testing and interview processes, including by not limited to claims based on any state or federal rights of privacy.

4. I acknowledge and agree that in the event of any claim or dispute that arises from my submission of this application and that cannot be resolved by initial direct communications between myself and the Company, the claim or dispute shall be resolved by binding arbitration. The American Arbitration Association (AAA) shall arbitrate such dispute unless another third party arbitrator is agree upon in writing by both parties. The arbitration shall be conducted either in accordance with the Model Employment Arbitration Procedures of the AAA which are in effect at the time of the arbitration or, if an alternative arbitrator is agreed upon, in accordance with the then current rules and procedures of that other third party arbitrator. I understand however that by this agreement, the arbitrator is prohibited from imposing any type of fees, costs or expenses upon me that I would not be required to bear if I were free to bring a legal action in court. I also understand that nothing in this agreement to arbitrate application-related disputes prohibits me from submitting a workplace-related administrative claim as permitted by federal, state or local law with any appropriate agency. In the event I am hired by the Company, then its published policies and procedures for resolution, mediation and arbitration of disputes with employees, including by not limited to those stated by the Company’s employment agreement shall replace this agreement to arbitrate.

5. I acknowledge and agree that nothing in this application and nothing in communications between me and Company representatives or associates during the application, interview and/or testing process is intended to create an offer of employment or a contract of employment between me and the Company. I further acknowledge and agree that if hired by the Company, nothing in this application and nothing in communications between me and Company representatives or associates during the application, interview and/or testing process and nothing in my employment is intended to create or should be construed to create anything other than “at-will” employment for no definite or determinable period, employment that may be terminated by either me or the Company at any time, for any reason or no reason at all and without prior notice. I further acknowledge and agree that no promises or representations contrary to any of the points made in these five numbered paragraphs are binding on the Company unless stated in writing and signed by me and an authorized Company Representative.

Date:

Signature:

Interviewed by:

DO NOT WRITE BELOW THIS LINE

NOTES:

Approved: 1.

2.

Personnel Manager Department or Division Head Executive Director

This document is copyright © 2007 Dr. Jose Alvarez, DDS. All Rights Reserved. It is derived with permission from Law Offices of Timothy Bowles from a copyrighted model form published by that firm and which bears the notice “copyright © 2007 Law Offices of Timothy Bowles, P.C. All Rights Reserved” Rev.

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