Nds Employment Work History Form
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1NDS EMPLOYMENT WORK HISTORY FORM
Previous Employment Please list for last seven (7) years – if necessary list on a separate page.
Company:
Position:
Address:
Supervisor:
City/State:
Supervisor Phone:
Company Phone:
Salary:
Dates Employed:
Reason for leaving:
Company:
Position:
Address:
Supervisor:
City/State:
Supervisor Phone:
Company Phone:
Salary:
Dates Employed:
Reason for leaving:
Company:
Position:
Address:
Supervisor:
City/State:
Supervisor Phone:
Company Phone:
Salary:
Dates Employed:
Reason for leaving:
Education
School
Location
Graduated
Major or Field of Study
High School
Graduated Y N
Vocational
(Date Graduated)
(Location)
College:
(Date Graduated)
(Location)
Professional References: Please list three (3) professional references
Full Name
Full Name:
Full Name:
Position:
Position:
Position:
Phone:
Phone:
Phone:
Company:
Company:
Company:
APPLICANT ACKNOWLEDGE AND AUTHORIZATION – PLEASE READ CAREFULLY BEFORE SIGNING
I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents is
correct, accurate and complete to the best of my knowledge. I understand that the fabrication, misrepresentation or omission of any facts
in said documents will be cause for denial of employment of immediate termination of employment regardless of the timing or
circumstances of discovery.
I understand that submission of an application does not guarantee or representation. I further understand that, should an offer of
employment or representation be extended by Nevada Dental Staffing that such employment or representation with Nevada Dental
Staffing is at will, for no specified duration and may be terminated by either Nevada Dental Staffing or myself at any time, with or without
cause or notice. I understand that none of the documents, policies, procedures, actions, statements of Nevada Dental Staffing are
consideration for employment or representation with Nevada Dental Staffing, if employed, I agree to conform to the rules, regulations,
policies and procedures of Nevada Dental Staffing at all times and understand that such obedience is a condition of employment of
representation.
I understand that if offered a position with Nevada Dental Staffing, I will be required to submit to a pre-employment background check as
a condition of employment and the results of this check may be provided to any clients to whom I am assigned. (Initial __________)
I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide
such information to Nevada Dental Staffing and/or any of its prospective employers and I release all parties included from any and all
liability for any and all damage that may result from providing such information. (initial _______________)
BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.
SIGNATURE: ________________________________________ DATE: ______ / _______ / _____________
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Parent category: Business