EMPLOYMENT APPLICATION

Transcription

1 Raintree Essix Glenroe th Ct E Sarasota, FL Phone: EMPLOYMENT APPLICATION DENTSPLY Raintree Essix Glenroe is an equal opportunity employer. Applicants are considered for positions for which they are qualified and associates are employed without regard to race, color, religion, sex, national origin, ancestry, creed, sexual orientation, disability, veteran or current military status, or any other characteristics protected by federal, state or local law. Please let us know if you are an applicant with a disability who needs an accommodation to participate in the application process. Personal Last Name: First: Middle: Permanent Address: Street (Apt #): City: State: Zip: County: Home Phone Number: Alternate/Cell Phone Number: ( ) - ( ) - Have you ever worked or attended school under another name that we need to know to verify your records? Yes No If yes, please provide: Position applying for: Salary desired: $ Are you 18 years of age or older? Yes No Were you ever employed by this division or any other division of DENTSPLY International Inc? Yes No If yes, give date and location: Reason for leaving: Are you willing to work a varied schedule, including weekend, holiday or overtime requirements? Yes No Availability: Full-Time Part-Time Temporary Nights Weekends Date you can start: Days you are available to work: Sunday Monday Tuesday Wednesday Thursday Friday Saturday How did you learn about this job? Company Career Website Other Career Website Employee Referral Agency Name Other Do you have any relatives or friends employed with this division or any other division of DENTSPLY International Inc? Yes No If yes, please list: Indicate languages which you speak, read, and write fluently: English Spanish Other Other Are you legally authorized to work in the United States? Yes No Expiration date, if any: Are you currently bound by a restrictive covenant or non-compete agreement? Yes No If yes, please explain: Educational History School Name and Location Course of Study Circle last year completed Did you graduate? Degree or Diploma High School College Graduate School Other

2 Employment History List your employers, starting with THE MOST RECENT OR PRESENT employer. Please give your accurate and complete full-time and part-time employment record. You must complete all fields even if you have submitted a resume. Name of Business: Name of Supervisor: Pay Rate: Start End $ $ Reason for Leaving Address: Phone Number: ( ) - Bonus/Commissions: $ Job Dates: Start End Duties and Responsibilities: Job Title: May we contact? Yes No Name of Business: Name of Supervisor: Pay Rate: Start End $ $ Reason for Leaving Address: Phone Number: ( ) - Bonus/Commissions: $ Job Dates: Start End Duties and Responsibilities: Job Title: May we contact? Yes No Name of Business: Name of Supervisor: Pay Rate: Start End $ $ Reason for Leaving Address: Phone Number: ( ) - Bonus/Commissions: $ Job Dates: Start End Duties and Responsibilities: Job Title: May we contact? Yes No Name of Business: Name of Supervisor: Pay Rate: Start End $ $ Reason for Leaving Address: Phone Number: ( ) - Bonus/Commissions: $ Job Dates: Start End Duties and Responsibilities: Job Title: May we contact? Yes No Provide explanation of any gaps in employment: Military Status in the United States Armed Forces Dates of Active Military Service (from to): Branch of Service: Rank at Discharge: Current Military Affiliation:

3 CRIMINAL CONVICTION INQUIRY AND STATE DISCLOSURE LIMITATIONS Have you ever been convicted of a crime (felony or misdemeanor)? Yes No Record (Note: If you are applying for a position in Hawaii, Massachusetts, or the City of Philadelphia, you should not answer this question until after you have received a conditional offer of employment.) Please review the below state disclosure limitations before responding. All applicants may answer No Record if a conviction has been sealed, pardoned, expunged, annulled, statutorily eradicated or dismissed upon condition of probation. If you answered yes, please provide date, place and nature for all conviction(s): A conviction will not necessarily disqualify you from employment with DENTSPLY RAINTREE ESSIX GLENROE. However, failure to disclose your complete conviction history will be considered falsification of the application and will be grounds for rejection of your application. California Applicants You may answer No Record with respect to any conviction for a marijuana offense if the conviction occurred more than two (2) years prior to the date this application is completed. In addition, do not provide any information regarding a referral to and participation in any pre-trial or post-trial diversion program. Connecticut Applicants You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or a. Criminal records subject to erasure pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or a are records related to (a) determinations of delinquency or that, as a child, you were a member of a family with service needs, (b) a ruling you are a youthful offender, (c) a finding you are not guilty for a criminal charge, or (d) a conviction for which you have received an absolute pardon. Any person whose criminal records have been erased pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or a shall be deemed to never have been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath. Hawaii Applicants Do not respond to this inquiry until you have been given a conditional offer of employment. If you are required to respond, please limit your responses to crimes for which you were convicted within the past ten (10) years, excluding periods of incarceration. Illinois Applicants You are not required to reveal any expunged convictions, including expunged juvenile convictions. Massachusetts Applicants Do not respond to this inquiry until you have received a conditional offer of employment. If you have a sealed record on file with the commissioner of probation you may answer No Record with respect to any inquiry herein relative to prior arrests, criminal court appearances or convictions. You may answer No Record with respect to any inquiry relative to prior arrests, court appearances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the superior court for criminal prosecution. In addition, you may answer No Record with respect to a first conviction for: (1) the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violation, affray or disturbances of the peace; or (2) any misdemeanor conviction where the date of conviction or any resulting incarceration occurred five (5) or more years ago. Utah Applicants You may answer No Record with respect to any conviction for a misdemeanor or summary offense. Washington Applicants Answer Yes only if the conviction or release from imprisonment was within the last ten (10) years, or related to the functions of the position for which you are applying. City of Philadelphia Applicants Do not respond to this inquiry until you have been given a conditional offer of employment.

4 ACKNOWLEDGEMENT AND RELEASE PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING: The information that I have provided is accurate to the best of my knowledge and subject to validation by DENTSPLY RAINTREE ESSIX GLENROE. I understand and agree that any misrepresentation or omission of fact in my application, in any supplement thereto, during any interview, or in any other employment-related records supplied or completed by me, shall be grounds for rejection of my application for employment or, if employed, for termination of my employment with DENTSPLY RAINTREE ESSIX GLENROE, regardless of the amount of time elapsed before discovery. I understand that an offer of employment and my continued employment with DENTSPLY RAINTREE ESSIX GLENROE are contingent upon satisfactory proof of my authorization to work in the United States. I understand that nothing contained in this employment application or in the granting of an interview or an offer of employment is intended to create a contract between myself and DENTSPLY RAINTREE ESSIX GLENROE for employment or for the providing of any benefit. No promises regarding continued employment have been made to me, and I understand that no such promise or guarantee is binding upon DENTSPLY RAINTREE ESSIX GLENROE unless made in writing and signed by me and an authorized representative of DENTSPLY RAINTREE ESSIX GLENROE. I understand that if I am employed by DENTSPLY RAINTREE ESSIX GLENROE, my employment will be terminable-at-will, and that either I or DENTSPLY RAINTREE ESSIX GLENROE may terminate my employment at any time, with or without cause, for any reason or no reason, and that I am not being employed for any specific term. I understand that business needs at times may make the following conditions mandatory: overtime, shift work, and rotating schedules. I understand and accept these conditions of employment. I understand that DENTSPLY RAINTREE ESSIX GLENROE may require a pre-employment investigation of my criminal conviction history, educational background, past employment, and activities that may relate in any way to my potential fitness for employment. I further understand that I may be required to take and pass a drug test as a condition of being hired at or transferred to a DENTSPLY RAINTREE ESSIX GLENROE location. I agree to complete all required authorization forms and provide all information necessary for DENTSPLY RAINTREE ESSIX GLENROE, or its agent, to conduct any required pre- employment investigation. If hired, I authorize DENTSPLY RAINTREE ESSIX GLENROE to conduct subsequent investigations during the course of my employment. I authorize schools and prior employers to provide any information they have concerning me to DENTSPLY RAINTREE ESSIX GLENROE, and I hereby hold harmless DENTSPLY RAINTREE ESSIX GLENROE and all those providing information from any liability that may arise out of or result from the provision or use of such information. Maryland Applicants: By signing below, you acknowledge receipt of the following notice: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100. Massachusetts Applicants: By signing below, you acknowledge receipt of the following notice: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability. I have read and understand the information provided above. Applicant Signature Date Applicant Printed Name

5 BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM In the interest of maintaining the safety and security of our customers, employees and property, (the Company ) will order a consumer report (a background report) on you in connection with your employment application, and if you are hired, or if you already work for the Company, may order additional background reports on you for employment purposes. The background check company, ADP Screening and Selection Services, will prepare the background report for the Company. ADP Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached at The background report may contain information concerning your character, general reputation, personal characteristics, mode of living, and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification; criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and certification checks; credit reports; and drug testing results. The information may be obtained from private and public record sources, including personal interviews with your associates, friends, and neighbors. (An investigative consumer report is a background report that includes information from such personal interviews, except in California where that term means any background report.) The nature and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history conducted by ADP Screening and Selection Services or another outside organization. You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company at - -. A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form. STATE SPECIFIC NOTICES If you live or work for the Company in the states listed below, please note the following: CALIFORNIA: You may view the file that ADP Screening and Selection Services has for you, and order a copy of the file, upon submitting proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable notice, or by mail. You may also ask for a file-summary by telephone. ADP Screening and Selection Services can answer questions about information in your file, including any coded information. If you come in person, another person can come with you, so long as that person can show proper identification. MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You may request the name, address, and telephone number of the nearest office for ADP Screening and Selection Services. You will get this information within 5 business days of our receipt of your request. You have the right to ask ADP Screening and Selection Services for a free copy of the report. MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an investigative consumer report from ADP Screening and Selection Services. You may inspect and order a free copy of the report by contacting ADP Screening and Selection Services. MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the consumer report or investigative consumer report ordered, if any. NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an investigative consumer report from ADP Screening and Selection Services, and you will be provided with the name and address of ADP Screening and Selection Services. You may inspect and order a free copy of the reports by contacting ADP Screening and Selection Services. A copy of Article 23A of the New York Correction Law is being provided with this form. OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask ADP Screening and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an unacceptable risk of theft or other dishonest behavior in the job for which you are being considered. Page 1 of 4 V0611

6 AUTHORIZATION FOR BACKGROUND CHECKS After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my background report, including investigative consumer reports. I understand that the Company may rely on this authorization to order additional background reports, including investigative consumer reports, during my employment without asking me for my authorization again as allowed by law. I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all information about or concerning me, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal history, military service, professional credentials and licenses and substance abuse testing. I agree the Company may rely on this authorization to order background reports, including investigative consumer reports, from companies other than ADP Screening and Selection Services without asking me for my authorization again as allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of my personal information on this form is true and correct and understand that dishonesty will disqualify me from consideration for employment with the Company, or if I am hired or already work for the Company, that my employment may be terminated. Last Name First Middle Maiden/Other Names Years Used Social Security Number Driver s License Number State FOR IDENTIFICATION PURPOSES ONLY: Date of Birth / / (Month/Day/Year) Addresses Within The Past Seven Years (use a separate sheet as needed) Present Street Address City/State/ZIP Prior Street Address From / / (Month/Day/Year) To / / (Month/Day/Year) City/State/ZIP / / Signature Date: (Month/Day/Year) If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy of your background check report: Page 2 of 4 V0611

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8 NEW YORK CORRECTION LAW ARTICLE 23-A LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY CONVICTED OF ONE OR MORE CRIMINAL OFFENSES Section 750. Definitions Applicability Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited Factors to be considered concerning a previous criminal conviction; presumption Written statement upon denial of license or employment Enforcement Definitions. For the purposes of this article, the following terms shall have the following meanings: (1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission. (2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more persons. (3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question. (4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: (1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or (2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules. 2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights. Page 4 of 4 V0611

9 Voluntary Self-Identification Form If you wish to voluntarily identify your ethnic origin, please indicate so by placing a Check mark ( ) in the appropriate box. ( ) Race Description African/American (Black) Asian American Indian or Alaskan Native Hispanic Native Hawaiian or other Pacific Islander Caucasian (White) Two or more Races Persons having origins in any of the Black racial groups of Africa Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent Persons having the origins in any of the peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or culture or origin, regardless of race Persons having origins of the Pacific Islands such as Hawaii, Japan, or the Philippines Persons having origins in any of the original peoples of Europe, North America or the Middle East. Not of Hispanic origin Persons having origins in more than one of the above identifying races. Not of Hispanic or Latino descent Please indicate status with a checkmark ( ) Gender Male Female Name Date