This is an application for employment at the dental offices of Mark D. Thebaut D.D.S., P.C., doing business as Tebo Dental Group, with locations in Lilburn, Peachtree Corners, Gainesville, Cumming, and Dacula.

Please answer all questions, even though some questions may not seem to be applicable to the position you are seeking. Please provide only the information that is requested in this application.

You are required to bring a printed version of your application in with you upon attending an in-person interview or Tebo Dental Career Event. If you would like to print a completed version of this form to bring in with you, you will have the option to download a .PDF version once your application has been filled out and submitted.

Personal

*Name

*Email Address

*Phone

*Address

*City

*State

*Zip

*Have you ever been convicted of a crime, other than a minor traffic offense?

Yes No

If so, please explain

Education

	Name & Address	Graduated?	# Years Completed	Major
High school		Yes No
College		Yes No
Dental Assistant School		Yes No
Hygienist School		Yes No

Certifications

	Certificate No	Date	State Issued	Current until (date)
CPR
X-ray
Dental Assistant
Expanded Duties
Other

References

*Please list three professional references such as former co-workers or employers. Please do not list close relatives.

Name

Relationship

Company

Occupation

Email Address

Phone

Name

Relationship

Company

Occupation

Email Address

Phone

Name

Relationship

Company

Occupation

Email Address

Phone

Applicant's Statement, Authorization and Release

Information Correct and Complete

The information in this application is correct and complete to the best of my knowledge. I authorize the practice to conduct whatever investigation the practice determines appropriate to verify the information I have provided. If I have made any misrepresentation or omission of material information in this application, the practice may withhold an offer of employment or, if I am hired, may terminate my employment immediately.

Authorization and Release concerning Information Provided

Except as I have indicated to the contrary in this application, I authorize all persons who may be contacted in connection with this application to provide any and all information concerning my previous employment or background. I release all such persons from liability for any damages that may result from providing such information to the practice.

Exams and Background Checks

If required for the position or as a result of any of my responses in this application, I will submit to a physical exam or drug test and I will authorize in writing a background check concerning my driving record, credit history and any criminal convictions.

Employment Offer

If the practice makes an offer of employment, the offer is conditioned upon receipt of satisfactory responses to reference and background inquires. If I am hired, I will provide proof of identity and authority to work in the U.S.

Employment at Will

If I am hired, my employment will not be for a definite period of time and the practice, in its sole discretion, may terminate my employment at any time, with or without cause and with or without advance notice.

Waiver concerning Public Records

*I waive my right to receive a copy of any public records that the practice may obtain in connection with this application.

Yes No

*Signature

Date:

Typing Speed: wpm
Microsoft Outlook	Yes No
Microsoft Word	Yes No
Microsoft Excel	Yes No
Bookkeeping	Yes No
QuickBooks	Yes No
Adding machine	Yes No
Handling insurance	Yes No
Dental terms	Yes No

Dental instruments	Yes No
Sealants	Yes No
Taking x-rays without Rinn Holders	Yes No
Orthodontics	Yes No
Pour Models	Yes No
Oral Evacuator	Yes No
Rubber Dam Application	Yes No
Temp Crown/Bridges Fabrication	Yes No

Employment Application