Great Lakes Orthodontics


 

Employment Application

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.
 
(Fields marked with an asterisk * are required)
*Position(s) Applied for:
* Date:
* Last Name:
  		* First Name:
  		Middle Name:
* Address:
  		* City:
  		* State:
  		* Zip Code:
* Home Phone:
() - -
Cell Phone:
() - -
E-mail:

How did you learn about us?

Advertisement (Name of publication):
Referral Agency (Please identify):
General Inquiry
Relative/Friend (Name):
Website (Please identify):
Other:

Have you ever worked under another name? Yes No

If Yes, what was it?

If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No

Have you ever filed an application with us before? Yes No

If Yes, give date

Have you ever been employed with us before? Yes No

If Yes, give dates

Do any of your friends, relatives, or your spouse, work here? Yes No

If Yes, give name(s)

Are you currently employed? Yes No

May we contact your present employer? Yes No

* Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No

(Proof of citizenship or immigration status will be required upon employment)

Have you ever been convicted of a felony (exclude misdemeanors and summary offenses)?
Yes No

If Yes, list date and describe in full. (Please Note: An affirmative response will not automatically exclude consideration for employment)


Date available for work

What is your desired salary (hourly) range?

Are you available for work?
   Full Time (Please indicate 1st, 2nd, 3rd shift)

   Part-Time:  Mornings   Afternoon   Evenings  

   Temporary (Please indicate dates available)
        -
Are you currently on 'layoff status' and subject to recall? Yes No

Can you travel if a job requires it? Yes No

 
EDUCATION

  Name and Address of School Course of Study Years Completed Diploma/Degree
Elementary School
High School
Undergraduate
Graduate/ Professional
Other (specify)


Describe any specialized training, apprenticeships, skills and extra-curricular activities.


Describe any job-related training received in the United States military.
Military Service Branch: Date(s): -



List professional, trade, business or civic activites and offices held (you may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status).

EMPLOYMENT EXPERIENCE

Start with your present or last job. Include any job-related military service assignments and volunteer activities.
Dates Employed: From To
Hourly Rate/Salary: Starting Final
Employer
Supervisor
Address
Reason For Leaving
Telephone Number
() - - 		Work Performed
Job Title

Dates Employed: From To
Hourly Rate/Salary: Starting Final
Employer
Supervisor
Address
Reason For Leaving
Telephone Number
() - - 		Work Performed
Job Title


Dates Employed: From To
Hourly Rate/Salary: Starting Final
Employer
Supervisor
Address
Reason For Leaving
Telephone Number
() - - 		Work Performed
Job Title


Dates Employed: From To
Hourly Rate/Salary: Starting Final
Employer
Supervisor
Address
Reason For Leaving
Telephone Number
() - - 		Work Performed
Job Title


Dates Employed: From To
Hourly Rate/Salary: Starting Final
Employer
Supervisor
Address
Reason For Leaving
Telephone Number
() - - 		Work Performed
Job Title

 
ADDITIONAL INFORMATION

Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.


Attendance and Punctuality
Consistent attendance and punctuality are essential requirements of every job with Great Lakes Orthodontics. Is there anything which would interfere with your regular attendance and punctuality if you are offered a job at Great Lakes Orthodontics?


State any additional information you feel may be helpful to us in considering your application.


References (List names of 3 persons not related to you who are able to comment on your work history)
1. Name:
Telephone:
() - - 		Address:
2. Name:
Telephone:
() - - 		Address:
3. Name:
Telephone:
() - -
Address:


Applicant's Statement

I certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 6 months. Any applicant wishing to be considered beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by law, any employment relationship with Great Lakes Orthodontics, Ltd. is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also, that I am required to abide by all rules and regulations of Great Lakes Orthodontics, Ltd.

* I have read and agree to the terms of the Applicant's Statement.
* Date:


Great Lakes Orthodontics, Ltd.
EEO Self-Identification Form

Government agencies require reports on the demographic make-up of new hires.  This data is for EEO analysis and affirmative action only.  Submission is voluntary.  Failure to provide this information will not jeopardize or adversely affect any consideration you may receive for hire or advancement in future employment opportunities.
Date:
Job applying for:

Male Female

Race/Ethnicity:
Hispanic or Latino  A person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin regardless of race.

OR
American Indian or Alaskan Native  (Not Hispanic or Latino) A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian  (Not Hispanic or Latino) A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American  (Not Hispanic or Latino) A person having origins in any of the Black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American".

Native Hawaiian or Other Pacific Islander  (Not Hispanic or Latino) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White  (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Two or more races  (Not Hispanic or Latino)

Veteran Status
Veteran: Yes No
  If yes, Vietnam Era Vet Disabled Vet     Date Discharged:

OR
I choose not to complete this form


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