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					                                         Community Medical & Dental Care, Inc.
                                                 Department of Human Resources
                              40 Robert Pitt Drive, Monsey NY 10952 P: 845-352-6800 F: 845-352-7293
                                                                               As an equal opportunity employer, Community Medical and Dental Care,
       Application for Employment                                              Inc. considers applications for all positions without regard to race, color,
                                                                               religion, sex, national origin, age, martial status, or disability, or any other
   Location: ______________________                                            protected classes as defined by federal, state, or local law.


Name ___________________________________________________________________________________________
        Last                                                      First                                          Middle
Address_________________________________________________________________________________________
               Number and street                                               City                                       State                          Zip Code

Telephone Number ( )_______________ Fax ( ) _________________ Cell ( )___________Email _____________________
How did you learn about this position? ___________________________ Do you know anyone on staff at CMADC?                                              Yes         No
Position Desired 1.__________________________ 2. ______________________________ Date available to start: ____________

Please check days/nights you can work: Please note: CMADC’s hours of operation are 7:30am to 9:00pm Sunday through
Friday, and Saturday evenings in the winter.
Days:            ____ Monday ____Tuesday ____Wednesday ____Thursday ____ Friday ____Saturday ____Sunday
Nights:         ____ Monday ____Tuesday ____Wednesday ____Thursday ____ Friday ____Saturday ____Sunday
_____ Full-time          _____ Part-time        Available for overtime? Yes No How many weekends/month? _________
Please list any days/times you cannot work: ______________________________________________________________________

Do you wish to advise us of your salary expectations?                     From $_________________ to $__________________

Please list any skills or training that you have received that is directly related to the position for which you are applying (include compu
and software programs in which you are proficient): ______________________________________________________________

Please list your interests, career goals, and expectations:___________________________________________________________

Please indicate all languages spoken: __________________________________________________________________________

Have you been convicted of a crime, other than a minor traffic violation, within the past 7 years?     Yes      No
If yes, please provide information regarding the nature of the offense (Note: a conviction will not necessarily bar you from
employment): _____________________________________________________________________________________________
Please note: A criminal background check may be performed for all applicants. If you consent to this, please provide your social
security number: _________________________

   EDUCATION                           Name of School, City and State             Diploma / Degree                                Major / Course Concentration
                                                                                  Diploma?  Yes  No
   High School                                                                               GED
                                                                                  Degree?
   College                                                                         Yes Type ____________
                                                                                   No Last Year Completed _______
                                                                                  Degree?
   Other
                                                                                   Yes Type _______________
                                                                                   No Last Year Completed ______


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Employment Record – Please start with most recent employer; include military service. If you are currently employed, may we contact your
present employer? Yes     No                                                                                    Notes:
   Name of Employer: _______________________________ Telephone ( ) _________________________

   Address: ______________________________________________________________________________

   Name of Immediate Supervisor: ___________________________ Title:____________________________

   Your Title and Duties: ___________________________________________________________________

   _________________________________________________Salary/Wage:__________________________

   Reason for Leaving: ________________________________ Employed From: _________ To: __________
                                                                                                                                               Notes:
   Name of Employer: _______________________________ Telephone ( ) _________________________

   Address: ______________________________________________________________________________

   Name of Immediate Supervisor: ___________________________ Title:____________________________

   Your Title and Duties: ___________________________________________________________________

   _________________________________________________Salary/Wage:__________________________

   Reason for Leaving: ________________________________ Employed From: _________ To: __________

                                                                                                                                               Notes:
   Name of Employer: _______________________________ Telephone ( ) _________________________

   Address: ______________________________________________________________________________

   Name of Immediate Supervisor: ___________________________ Title:____________________________

   Your Title and Duties: ___________________________________________________________________

   _________________________________________________Salary/Wage:__________________________

   Reason for Leaving: ________________________________ Employed From: _________ To: __________
                                                                                                                                               Notes:
                              Non-personal references, preferably supervisors
   Name: _____________________________________         Relation ______________ Tel _________________

   Name: _____________________________________                        Relation ______________ Tel _________________

   Name: _____________________________________                        Relation ______________ Tel _________________


   Applicants may be required to undergo a drug screening as a condition of being hired. A positive test result will make applicant ineligible to be hired. Successfully passing
   a drug test does not guarantee being hired or job availability.
   Important, Please Read Carefully: I certify that the information given by me to CMADC is true and complete to the best of my knowledge. I understand that, if I am on
   staff, the discovery that I gave false or misleading information, or that I omitted any material information may result in my immediate dismissal. I authorize CMADC to
   solicit information regarding my character, general reputation, previous employment and similar background information from third parties, and to contact any and all
   references I have on my application. I hereby release all parties and persons connected with such request for information from all liability and damages arising out of the
   furnishing of such information. If on staff, I release CMADC. from any liability for future references it may provide regarding my work history at the company. In
   consideration of my being hired, I agree to conform to the rules and regulations of Community Medical and Dental Care, Inc. I understand that my being on staff
   (and the terms and benefits provided or paid to me) is “at will”, and is not intended to, and does not constitute a contractual relationship, and that my status of
   “at will” will not change. If I am hired I understand that I will be obligated to adhere to the policies and procedures of CMADC.


 Signature: ____________________________________________________                                     Date: ________________________________

                                                                          OFFICE USE:
Position:__________________________                     Location:       Monsey   SV   Dental Van                    Starting Date_______________________



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posted:3/29/2013
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