UPDATE YOUR EMPLOYMENT FILE

Let us know what you've been up to and what your current needs are. Only complete those sections where changes apply.  Welcome back! We are looking forward to working with you in the future.

Personal Information:

Last Name   First Name   Middle Initial

Address    

City                        State   Zip

SS #                       Birthdate    

Phone 1st               Phone 2nd 

E-Mail       

Have you ever been? Arrested (Yes/No) Convicted of a Crime?(Yes/No) 

If YES in Arrested and/or Convicted; Must give all dates and details below.

Answering YES to above questions does not necessarily disqualify you from employment.

Please check areas where you are willing to take a permanent or temporary assignment.

Education:

NAME/LOCATION OF SCHOOL                                                                 GRADUATED          YEAR

High School (City, State)          YES NO      

Technical (City, State)              YES NO      

College (City, State)                 YES NO        

Please type your name in the box if you authorize the above W-4 information to be released to specific client-dentists for payroll purposes only.          Employee's electronic signature

OR

      I will only accept work as an independent contractor, be in control of my own hours, schedule and performed duties.  

    I FULLY UNDERSTAND THIS MAY AFFECT HOW MUCH WORK IS REFERRED TO ME AND WILL BE CONSIDERED A REFUSAL OF WORK IN CERTAIN CASES. 

Required Forms:

Please print and complete the following forms and return to Dental Staffing at the address below.  Your prompt attention will help prevent payroll delays. 

Payroll Forms Packet (needed for payroll purposes)                  

Click here to download Adobe Reader needed for viewing these documents.

OR

       I will only accept work as an independent contractor, be in control of my own hours, schedule and performed duties.     I FULLY UNDERSTAND THIS MAY AFFECT HOW MUCH WORK IS REFERRED TO ME AND WILL BE CONSIDERED A REFUSAL OF WORK IN CERTAIN CASES.

By typing my name below, I affirm that all  information submitted on this application is true and correct.

Employee's electronic signature

Please send copies of the following:

1.  Florida Dental/Hygiene License (if applicable)

2.  CPR Card

3.  X-ray Certification/License (if applicable)

4.  Expanded Functions Certification (if applicable)

5.  Orthodontics Certification (if applicable)

6. Drivers License/Identification Card

7. Social Security Card

8. Updated Resume

9. Letters of recommendation (if applicable)

Email dss@dentalstaffingsolutions.com

Mail: P.O. Box 21524,St.Petersburg,Fl 33742-1524

Fax: 727-546-3500