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Pediatric Teledentistry
Photo Guide to a Pediatric Teledentistry Visit
Pediatric Teledentistry Consent Form
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First Visit
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Home
Pediatric Teledentistry
Photo Guide to a Pediatric Teledentistry Visit
Pediatric Teledentistry Consent Form
Bean Visits
First Visit
Dental Care for Beans
Frenectomies for Infants and Toddlers
Postprocedure Care
Patient Forms
Common Questions
Provider Referral
BeanCare Packages
About the Bean
The BeanTeam
Office Tour
Office Policies
Work with the Bean
The Kinder Foundation
BeanStore
Dental Care
BeanCare Packages
Toothbrushes
Toothpaste – NonRX
Floss
Teething Necklaces and Bracelets
Coffee and Drinkwear
Coffee and Mugs
Wearable Gear
Apparel
Application for BeanTeam Status
Step 1 of 6 - Ready to Rock?
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Todays' date:
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Personal Background Information
Your full name:
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Your email address:
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Your phone number:
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Your address:
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Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Have you ever been convicted of a felony which is substantially related to the functions or qualifications of the position(s) for which you are applying? Note: This question does not apply to convictions which have been expunged, sealed, pardoned or otherwise exonerated or eradicated. (A conviction record will not necessarily be a bar to employment.)
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Yes
No
If yes, please explain:
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Have you ever been convicted of healthcare fraud or listed by a governmental agency as excluded, debarred, or otherwise ineligible to participate in federally funded healthcare programs?
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Yes
No
If yes, please fully describe the criminal conviction(s) and list the nature of the offense(s):
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BeanTeam Positions
Position you are applying for:
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Pediatric Dentist
Dental Hygienist
Dental Assistant
Front Office/Scheduling Assistant
Sterilization Assistant
Position Type
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Full Time
Part Time
Either one is cool!
Date you are available to start work:
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What are your PER HOUR salary requirements?
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DO NOT reply with "Open" or "Negotiable"
Educational Background
High school:
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Highest level completed:
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Select one
9
10
11
12
College or technical school:
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Highest level completed:
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Select one
Technical Certificate
Associate Degree
Bachelors Degree
Masters Degree
PhD
Did you receive a degree or certificate?
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Yes
No
In progress
Type of Degree or Certificate
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Degree/Certificate
Date Received
Please list any other specialized training, certifications or qualifications:
Type
Date received
To add more certifications, click the "+" at the end of the form field.
Work History
Please list below your employers, starting with last or present place of employment.
(you may include any verifiable work performed on a volunteer basis, internship or military service.)
Current or last employer
Name of employer:
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Employers phone number:
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Name of supervisor:
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Employers Address:
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Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is this your current employer?
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Yes
No
When did you start?
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Start date:
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End date:
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Reason for leaving:
*
Your position:
*
Describe your duties and responsibilities:
*
Please tell us what you did at this place of employment.
May we contact this employer?
*
Yes
No
If no, please explain:
*
Employer Two
Name of employer:
*
Employers phone number:
*
Name of supervisor:
*
Employers Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Start date:
*
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End date:
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Reason for leaving:
*
Your position:
*
Describe your duties and responsibilities:
*
Please tell us what you did at this place of employment.
May we contact this employer?
*
Yes
No
If no, please explain:
*
Employer Three
Name of employer:
*
Employers phone number:
*
Name of supervisor:
*
Employers Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Start date:
*
Month
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1931
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1928
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1926
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1922
1921
1920
End date:
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Month
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1925
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1922
1921
1920
Reason for leaving:
*
Your position:
*
Describe your duties and responsibilities:
*
Please tell us what you did at this place of employment.
May we contact this employer?
*
Yes
No
If no, please explain:
*
References
Please give the names of three additional work-related references whom we may call. Please do not list relatives or people you have not worked with in the past. Individuals with no prior work history may list school or volunteer-related references.
Reference One
*
Name
Position
Company
Contact Information
Reference Two
*
Name
Position
Company
Contact Information
Reference Three
*
Name
Position
Company
Contact Information
Applicant Certification
I understand that this application is not a contract, offer or promise of employment. I acknowledge that employment with the company is on an employment at-will basis. This means that my employment with the company can be terminated at any time, with or without cause or advance notice and acceptance of employment is not a contract of employment for any specified time. Similarly I am free to terminate my employment with the company at any time for any reason.
I further understand that I am responsible for being familiar with the company's policies, rules and regulations, and I understand that the company has complete discretion to modify its policies, rules, regulations and practices at any time, to the extent permitted by federal, state and local law, except that it will not modify its policy of employment at will. By my continued employment with the company, I consent to any such changes.
I certify that the above information is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation or omission of information on this form or relating to my application of employment may result in my denial of employment, or if employed, my immediate dismissal.
I hereby authorize the company or its agents to confirm all statements contained in this application and/or resume to the extent permitted by federal, state or local law and I agree to complete any requisite authorization forms. I release all parties from any liability arising out of this provision and the use of such information.
Attach your resume:
*
Accepted file types: pdf, doc, docx, png, jpg, jpeg.
Signature
*
Name
This field is for validation purposes and should be left unchanged.
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