Application

Your Information
Name*
FirstLast
Upload A Photo Of You (Optional)
Email*
*Must be accurate in order to receive your conformation.
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Date Of Birth*
MM
DD
YYYY
Social Security Number*
Home Phone*
Cell Phone
Work Phone
Emergency Contact*
FirstLast
Emergency Contact's Phone Number*

More Information
Year/Make Of Car/Color*
Drivers License Number*
RDH License Number
Graduation Date
MM
DD
YYYY
Type
- RDH
- CDA
- FD
Expanded Functions
- Yes
- No
Radiology License
- Yes
- No
Is there anything to know about you? (health, children, current commitments)

Refrences
First
Name*
FirstLast
Occupation*
Phone*
Years Known
Second
Name*
FirstLast
Occupation*
Phone*
Years Known
Third
Name*
FirstLast
Occupation*
Phone*
Years Known

Your Resume
Upload Your Resume

Agreement for Temporary or Permanent Placement
*
- Dental One, Inc. shall refer you to offices for temporary or permanent placement. You act as an independent contractor responsible for your own taxes and insurance except if hired on a permanent basis. Workers compensation will not be honored working in a temporary capacity.
*
- Applicant will have in their possession licenses and credentials (i.e., CPR, Hepatitis Vaccine, RDH, CDA, Radiology & CEU’s) available for review by the offices referred and upon registration with DENTAL ONE. Licensure renewal will be forwarded to our company in a timely manner as set by the D.P.R of Florida.
*
- Applicant also agrees not to divulge a telephone number or numbers to any office with the intent to contact them for future placement without the permission of DENTAL ONE, Inc. You will be responsible for a fee within one year from the date you are placed in the office if this would take place without DENTAL ONE, Inc. knowledge.
*
- Any referrals from offices referred by DENTAL ONE, Inc. must be directed through DENTAL ONE, Inc. either for temporary or permanent placement.
*
- Applicant agrees to conduct themselves in a professional capacity at all times, to comply with OSHA, to report to the offices in a timely and punctual manner.
*
- Applicant agrees they will not discuss income with any other associate.
*
- Applicant agrees to abide by all patient confidentiality records. No discussion or information to be taken from patient records, whatsoever.
*
- Applicant agrees to hold harmless DENTAL ONE, Inc. from any liability due to lost or broken instruments and/or equipment.
*
- Applicant may not obtain the names of offices, doctors, or staff members to be used to compete with DENTAL ONE, Inc. and its method of operation.
Virtual Signiture*
FirstLast

Default & Attorney's Fees
In the event of default under the terms of venue shall be held in Palm Beach County, Florida, and each party agrees to this contract, then the prevailing party shall be entitled to all costs and reasonable attorney’s fees including fees on appeal. The parties agree that waive trial by
Agreement*
- I hereby acknowledge I have read and understand this agreement and will abide by its contents.
Virtual Signiture*
FirstLast
Hepatitis B
Hepatitis B is a viral infection caused by hepatitis B Virus (HBV), which may cause death. Most people with Hepatitis B recover completely; but approximately 5% - 10% become chronic carriers of the virus. Most of these people have no symptoms, but can continue to transmit the disease to others. There is no evidence that the vaccine has ever caused hepatitis B. The incidence of side effects is very low. Prior to receiving the vaccine, you should be tested to see if you are already immune. If so, vaccination is not necessary at this time.
Vaccination Information*
- I have had the vaccination.
- I have not had the vaccination.
- I have declined the vaccination.
Agreement*
- I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infectious).
Virtual Signiture*
FirstLast
Authorization For Drug Testing
Agreement*
- Dental One, Inc prides itself with providing top quality candidates to the dental community. In order to do so, we MAY have a requirement for an initial drug test. I authorize Dental One, Inc. to perform an initial drug test for eligibility and also authorize future random drug testing when necessary.
Virtual Signiture*
FirstLast

Overall Agreement
Honor Code*
- I hereby agree that everything on this application is 100% true and application is subject to a background check.
U.S. Citizenship*
- I hereby agree that I am a United States citizen.
Virtual Signiture*
FirstLast

Application: For Applicants

Step 1 of 8

Your Information

More Information

Refrences

First

Second

Third

Hours & Availability + Extras

Your Resume

Agreement for Temporary or Permanent Placement

Default & Attorney's Fees

Hepatitis B

Authorization For Drug Testing

Overall Agreement

Quality Staffing

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