Acme Medical Company

Employment Application
Applicant Information
Full Date
Name: Magsi Nahl : 3/24/17
Last First M.I.

Address: 111 main st

Street Address Apartment/Unit #

Cary NC 27513
City State ZIP Code

Emai
Phone: 999-333-4444 l [email protected]

Date Social Security Desired

Available: 4/1/17 No.: 989-78-9898 Salary: $72,330

Position Applied
for: Dental Higienist

YE
Are you a citizen of the United YES NO If no, are you authorized to work in the S NO
States? x U.S.?

Have you ever worked for this YES NO If yes,

company? x when?

Have you ever been convicted of a YES NO

felony? x

If yes,
explain:

Education
High Wake Early College Addres
School: High School s: 2901 Holston Ln

Did you YES NO Diplom

From: 2013 To: 2017 graduate? x a:: Yes

Colleg Addres
e: UNC Chapel Hill s: Chapel Hill NC

Did you YES NO Degree

From: 2017 To: 2020 graduate? x : Associates

Other Addres
: s:

Did you YES NO Degree

From: To: graduate? :

1
 References
Please list three professional references.
Full Relationshi
Name: Karen Anne p: Friend
Compan
y: Dentistry Phone: 919-222-2222
Address: 201 cary pkwy

Full Relationshi
Name: Todd Bovenizer p: Friend
Compan
y: Bovenizer Orthodontics Phone: 919-254-8888
Address: 189 apple dr

Full Relationshi
Name: Erika Perez p: Friend
Compan
y: Cary Parkway dentistry Phone: 789-364-8989
Address: 7890 cary park way

Previous Employment
Compan
y: Cary Park Way Dentistry Phone: 919-893-8888
Superviso
Address: Cary Park Way r: Anne Lane

Starting
Job Title: Dental Hygienist Salary: $69,474 Ending Salary: $256,900

Responsibiliti Cleaned stains from teeth, took x ray, told patients how to maintain clean
es: teeth

To Reason for
From: 2015 : 2016 Leaving: New job

May we contact your previous supervisor for a YES NO

reference? x

Compan
y: Karen dentistry Phone:
Superviso
Address: 233 apple dr r: Karen Torres

Starting
Job Title: Dental Hygienist Salary: $71,234 Ending Salary: $305,234

Responsibiliti Cleaned Stains from teeth, x-ray, told patients how to maintain good oral
es: health.

To Reason for
From: 2016 : 2017 Leaving: didnt leave

2
May we contact your previous supervisor for a YES NO
reference? x

Compan
y: Phone:
Superviso
Address: r:

Starting
Job Title: Salary: $ Ending Salary: $

Responsibiliti
es:

To Reason for
From: : Leaving:

May we contact your previous supervisor for a YES NO

reference?

Military Service
Branc
h: From: To:

Rank at Type of
Discharge: Discharge:

If other than honorable,

explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my
application or interview may result in my release.
Signatur Date
e: Nahl Magsi : 3/24/17