APPLICATION FOR EMPLOYMENT WITH WILLIAM J. TREPP DDS PA
PLEASE COMPLETE PAGES 1-5							DATE _____________________________
Name _______________________________________________________________________________________
Last First Middle Maiden
Present address _______________________________________________________________________________
Number Street City State Zip
How long ___________________				Social Security No. _______ – _____ – _________
Telephone ( ) Best time of day to contact you at this number _____________________
If under 18, please list age:__________ Can you legally work in the United States? Yes No
Position applied for (1)_______________________ and salary desired (2) ______________________ (Be specific)					Days/hours available to work No Pref _______ Thur _________ Mon __________ Fri __________ Tue __________ Sat _________ Wed _________ Sun _________
How many hours can you work weekly? ________ Can you work nights? Yes No
Employment desired: FULL-TIME ONLY PART-TIME ONLY FULL- OR PART-TIME
When available for work? __________ Can you travel to out of state CE courses for 3 to 6 days each year? Yes No
_____________________________________________________________________________________________
TYPE OF SCHOOL	NAME OF SCHOOL	LOCATION (Complete mailing address)				NUMBER OF YEARS COMPLETED		MAJOR & DEGREE
High School
College
Bus. or Trade School
Professional School
HAVE YOU EVER BEEN CONVICTED OF A CRIME? Yes No
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation. ____________________________________
_____________________________________________________________________________________________
			CLINICAL POSITION ONLY

Have you passed the Maryland Qualified Dental Assisting Exam? Yes No Are you X-ray certified? Yes No

Are you a “Dentist – Orthodontics” in Maryland? Yes No Are you a Certified Orthodontic Assistant (COA)? Yes No

APPLICATION FOR EMPLOYMENT WITH WILLIAM J. TREPP DDS PS
Do you have child care to cover the hours of employment that you are applying for? Yes No
Do you have a driver’s license? Yes No Are you insured motorist? Yes No
What is your means of transportation to work? _________________________________________________________
Driver’s license number ___________________________ State of issue _______ Operator Commercial (CDL) Chauffeur
Expiration date ______________________
Have you had any accidents during the past three years? Yes No			How many? _______________
Have you had any moving violations during the past three years? Yes No			How Many? _______________
	OFFICE POSITION ONLY
Have you been bonded? Yes No Have you used Quicken software? Yes No
Yes Word Yes Typing No _____ WPM Processing No _____ WPM
Personal Yes PC Computer No Mac		Other _______________________________________ Skills _______________________________________
Please list two references other than relatives or previous employers.
Name ______________________________________		Name ______________________________________
Position _____________________________________		Position _____________________________________
Company ___________________________________		Company ____________________________________
Address ____________________________________		Address _____________________________________
_____________________________________		_____________________________________
Telephone ( )		Telephone ( )
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying. Please use your own handwriting. DO NOT PRINT OR TYPE THIS SECTION!

APPLICATION FOR EMPLOYMENT WITH WILLIAM J TREPP DDS PA
		MILITARY
HAVE YOU EVER BEEN IN THE ARMED FORCES? Yes No
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD? Yes No
Specialty _________________________________ Date Entered ________________ Discharge Date ___________
Work Experience	Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer Address			Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number				From To	Start Final
			Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address			Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number				From To	Start Final
			Your Last Job Title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

APPLICATION FOR EMPLOYMENT WITH WILLIAM J. TREPP DDS PA
Work experience	Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.
Name of employer Address		Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number			From To	Start Final
		Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address		Name of last supervisor	Employment dates	Pay or salary
City, State, Zip Code Phone number			From To	Start Final
		Your last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
May we contact your present employer? Yes No
Do you use tobacco? Yes No Are you right or left handed? ____________________________
Do you have any medical conditions that will limit your ability to perform job applied for, or would be aggravated by the job applied for? Yes No If yes, what are the conditions and your limitations? ___________________________________ ____________________________________________________________________________________________________
Did you complete this application yourself? Yes No If no, who did? __________________________________
Signature of Applicant___________________________________ Date___________________________________

PLEASE READ CAREFULLY

JOB APPLICATION FORM WAIVER

In exchange for the consideration of my job application by William J. Trepp, DDS, PA (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of the Company or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Company. Both the undersigned and the Company, may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I further understand that continued employment may be based on the successful passing of job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Signature of applicant__________________________________________ Date: ___________________

Thank you for completing this application form and for your interest in joining our business.

Return this application to: William J. Trepp DDS PA, 3020 Mountain RD, Pasadena, MD 21122-2016