Employment Application Form | Michael D. Vaughan - Special Needs and General Dentistry in Nashville, TN

Thank you for your interest in working with us

Please complete this Application for Employment Form. Give us a call if you need any help.

Applicant Information

Name:(* required)

First Middle Last

Address:(* required)

Street Address Address Line 2 City State ZIP Code

Social Security Number(* required)

Mobile Phone:(* required)

Home Phone:

Email:(* required)

Please attach your resume:

Drop files here or

Max. file size: 256 MB.

Employment Information

Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? (You will be required to provide documentation)(* required)

Yes
No

Have you ever been convicted of a felony (this will not necessarily affect your application)?(* required)

Yes
No

If yes, please describe conditions:(* required)

Position applied for?(* required)

How did you hear about this opening?(* required)

Have you ever applied for employment here?(* required)

Yes
No

If yes, please describe when, position, etc:(* required)

Dental Certificates or Licenses

Please attach your current License and current CPR/BLS or ALS Certification

Drop files here or

Max. file size: 256 MB.

Additional comments, licenses not current, etc:

Education

High School (school name, year, etc):(* required)

College (college name, year, major, degree, etc):(* required)

Write n/a if not applicable

Post-college or other training

In addition to your education history, are there other skills, qualifications or experience that we should consider?

Please list any scholastic honors received and offices held in school/college:

Employment History (most recent position)

Company name:(* required)

Company address:(* required)

Street Address Address Line 2 City State ZIP Code

Company phone:(* required)

Date started:(* required)

Still employed?(* required)

Yes
No

Date ended:(* required)

Ending position:(* required)

Ending wage:(* required)

Name of Supervisor:(* required)

May we contact?(* required)

Yes
No

Responsibilities:(* required)

Reason for leaving:(* required)

If listed job is less than 10 years, please list additional job history(* required)

More than 10 years
Less than 10 years

Job History (2)

Company name (2):(* required)

Company address (2):(* required)

Street Address Address Line 2 City State ZIP Code

Company phone (2):(* required)

Date started (2):(* required)

Date ended (2):(* required)

Ending position (2):(* required)

Ending wage (2):(* required)

Name of Supervisor (2):(* required)

May we contact (2)?(* required)

Yes
No

Responsibilities (2):(* required)

Reason for leaving (2):(* required)

If all listed jobs above sum less than 10 years, please list additional job history(* required)

More than 10 years
Less than 10 years

Job History (3)

Company name (3):(* required)

Company address (3):(* required)

Street Address Address Line 2 City State ZIP Code

Company phone (3):(* required)

Date started (3):(* required)

Date ended (3):(* required)

Ending position (3):(* required)

Ending wage (3):(* required)

Name of Supervisor (3):(* required)

May we contact (3)?(* required)

Yes
No

Responsibilities (3):(* required)

Reason for leaving (3):(* required)

References, not related to you, who have know you for more than 1 year

Name (professional reference) 1:(* required)

Phone (professional reference) 1:(* required)

Years known (professional reference) 1:(* required)

Please enter a number from 0 to 99.

Email (professional reference) 1:(* required)

Relationship (professional reference) 1:(* required)

Name (personal reference) 2:(* required)

Phone (personal reference) 2:(* required)

Years known (personal reference) 2:(* required)

Please enter a number from 0 to 99.

Email (personal reference) 2:(* required)

Relationship (personal reference) 2:(* required)

Name (personal reference) 3:(* required)

Phone (personal reference) 3:(* required)

Years known (personal reference) 3:(* required)

Please enter a number from 0 to 99.

Email (personal reference) 3:(* required)

Relationship (personal reference) 3:(* required)

Please list 2 emergency contacts

Name (contact 1):(* required)

Phone (contact 1)

Relationship (contact 1):(* required)

Name (contact 2):(* required)

Phone (contact 2)

Relationship (contact 2):(* required)

Please read and complete before signing

I certify that all information provided by me on this application is true and complete to the best of my knowledge and that I have withheld nothing that, if disclosed, would alter the integrity of this application.(* required)

I confirm!

I certify and affirm that, to the best of my knowledge and belief; I HAVE / I HAVE NOT (please indicate choice) had a case of abuse, neglect, mistreatment or exploitation substantiated against me.(* required)

I have not
I have (had a case of abuse, neglect, mistreatment or exploitation substantiated against me)

As a condition of submitting this application and in order to verify this affirmation, I further release and authorize Michael D. Vaughan, D.D.S., the Tennessee Department of Intellectual and Developmental Disability and the Bureau of TennCare to have full and complete access to any and all current or prior personnel or investigative record, from any party, person, business, entity or agency, whether governmental or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment or exploitation and to consider this information as may be deemed appropriate. This authorization extends to providing any applicable information in personnel or investigative reports concerning my employment with Michael D. Vaughan, D.D.S. to my future employers who may be Providers of DIDD services.(* required)

I confirm

I agree that Michael D. Vaughan, D.D.S. and my previous employers will not be held liable in any respect if a job offer is not extended, or is withdrawn, or employment is terminated because of false statements, omissions, or answers made by me on this application. In the event of any employment with Michael D. Vaughan, D.D.S., I will comply with all rules and regulations as set by Michael D. Vaughan, D.D.S. in any communication distributed to the employees.(* required)

I agree

In compliance with the Immigration Reform and Control Act of 1986, I understand that I am required to provide qualifying documentation to Michael D. Vaughan, D.D.S. that verifies my right to work in the United States on the first day of employment.(* required)

I understand

I understand that employment at Michael D. Vaughan, D.D.S. is “at will,” which means that either I or Michael D. Vaughan, D.D.S. can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I hereby acknowledge that I have read and understand the above statements.(* required)

I understand

Submit

Do you wish to receive a copy of this form?(* required)

Yes
No

E-mail address:(* required)

Please sign(* required)

Important: You consent to sign this document electronically.