Careers – Port City Dental

Full Name*
Email*
Phone*
Address*
City*
State*
ZIP*
Are you at least 18 years old?*
- Yes
- No
Are you legally eligible to work in the U.S.?*
- Yes
- No
Proof of U.S. citizenship or immigration status is required if hired.

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Position(s) applied for:*
Please select one:*
- Full-time
- Part-time
- Temporary
If hired, when would you be able to start?*
Have you ever worked for Port City Dental before?*
- Yes
- No
List any friends or relatives employed by Port City Dental:
If hired, do you have reliable transportation to get to work?*
- Yes
- No
Tell us about your availability. When would you prefer to work?*
List times you are NOT available to work:*

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Education (select the highest level achieved)
Secondary
- 9
- 10
- 11
- 12
- G.E.D.
College
- 1
- 2
- 3
- 4
- 5+
Schools
Name of School Location Degree/Major/Minor
Additional relevant education, training, or certifications:

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Are you currently employed?*
- Yes
- No
Previous Employers
Company
City/State
From | To:
Position
Duties
Salary Start/End:
Reason for leaving:
Supervisor's Name/Title
May we contact?
- Yes
- No
Phone
Company
City/State
From | To:
Position
Duties
Salary Start/End:
Reason for leaving:
Supervisor's Name/Title
May we contact?
- Yes
- No
Phone
Company
City/State
From | To:
Position
Duties
Salary Start/End:
Reason for leaving:
Supervisor's Name/Title
May we contact?
- Yes
- No
Phone

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Terms & Disclosures
AUTHORIZATION (please read carefully, then sign and date below) I certify that I have personally completed this application. I declare that the information provided in this employment application is true and complete and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for dismissal from employment if discovered at a later date. I agree to immediately notify this company if I should be convicted of a crime while my job application is pending or during my employment, if hired. I authorize this company to make an investigation of all information contained in this employment application and I release from liability all companies and corporations supplying such information. I understand any false answers, statements, or implications made by me on this application or other required documents shall be considered sufficient cause for denial of employment or discharge. I specifically authorize and direct my current and former employers to supply employment-related information to this company and do hereby release my current and former employers from liability for providing information to this company. Upon termination of my employment for whatever reason, I release this company from all liability for supplying any information concerning my employment to any potential employer. I authorize this company, if applicable, to request a copy of my credit report, motor vehicle driving record, and any other investigative report deemed necessary through various third party sources. As required by law, upon request within a reasonable period of time, I will be notified as to the nature and scope of such investigations.

AT-WILL EMPLOYMENT AGREEMENT I understand and agree that nothing contained in this application, or conveyed during any interview is intended to create an employment contract between the company and me. In addition, I understand and agree that if you employ me, in consideration of my employment, my employment and compensation will be at-will, for no definite period of time, and may be terminated at any time, for any reason, or for no reason at all. I understand that only the company’s President is authorized to change the employment-at-will status and such a change can only be done in writing. I have read, understand, and agree to the above.
Signature*

Enter your full name to sign
Date*
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Employment Application

Name of School	Location	Degree/Major/Minor