Employment Application Form

(PLEASE ENTER YOUR INFORMATION ACCURATELY)

Social Security #

Application for position as Today's Date
Name: First Middle Last
Phone # E-mail Address
Address State Zip
If you are under the age of 22, and applying for a position that requires you to serve alcohol, please state your date of birth: Pick Date
Are you authorized to work in the United States?
Date able to start Pick Date Pay Expected
Are you available to work full time?

How many hours do you expect to work a week? Minimum Maximum
If not, what hours can you work?
Indicate the shifts you are available to work by marking a check in the boxes below.

High school attended Did you graduate?
College attended Numbers of years completed
Major/Minor Did you graduate?

Please list any special abilities or knowledge which you have that are related to the job for which you are applying. (Please do not list those items which are related to race, sex, religion, color, national origin, age, marital status, disability or non-job related medical conditions):

In addition to work experience described in this application, what other experiences, skills, or abilities do you have that should be considered in evaluating your qualifications for this job?

EMPLOYMENT EXPERIENCE (start with the most recent)

1. Name of Company    Dates of employment
    Name of Supervisor    Phone #
    Job Title   Reason for Leaving
    Duration: From Pick Date  To Pick Date

2. Name of Company    Dates of employment
     Name of Supervisor    Phone #
     Job Title    Reason for Leaving     Duration: From Pick Date  To Pick Date

3. Name of Company    Dates of employment
     Name of Supervisor    Phone #
     Job Title    Reason for Leaving     Duration: From Pick Date  To Pick Date

REFERRAL SOURCE:		Advertisement		Employee		Relative		Govt Employment Agency
		Walk-in		Other

Do you have a relative working for Teresa DeGuzman, DDS Corp.? If so, where and what is his / her position?

REFERENCES

1. Name Phone# Years Known

2. Name Phone# Years Known

Will you abide by the safety rules of this company?

Have you ever been convicted of a felony, pled guilty to a felony resulting in a conviction, or been placed on probation (except in CA) for a felony offense? In California, exclude any conviction more than 2 years old for a marijuana-related offense.

(Conviction will not necessarily disqualify an applicant for employment, but date and type of conviction may be considered for job placement.)

If Yes	Date	Nature of Conviction	Where	Disposition
	Pick Date

PLEASE READ THE FOLLOWING CAREFULLY BEFORE SUBMITTING THE ABOVE INFORMATION

I declare that I am qualified to perform all the duties of the position I am seeking. I also declare that the information I have provided on this application is correct and that any false statements or omissions will justify my rejection or dismissal. I authorize the company to contact any of my previous employers as well as any reference source to verify the facts and information I have furnished regarding information provided on this application, on my resume, or during my interview. I authorize any person(s) having knowledge to provide such information to the company, and release from liability and agree to hold harmless any person that furnishes such information in good faith, as allowed by applicable state and federal laws. I will agree to a drug test, if permitted by law, to be paid for by the company. Should I become involved in a claim for worker's compensation or any other litigation after employment by the company, I will allow the company to supply my employment records ( as allowed by applicable state and federal laws) to an opposing party. If employed by the company, I understand that I will be an employee at will and that my employment with Teresa DeGuzman, DDS Corp. or any of its subsidiaries or affiliates (collectively "Teresa DeGuzman, DDS "), may be terminated at anytime by myself or Teresa DeGuzman, DDS for any reason whatsoever. Should I become employed by Teresa DeGuzman, DDS, I also authorize Teresa DeGuzman, DDS to conduct any additional background checks should they become necessary at any point during my employment. I also understand that the terms of my employment shall be based on all provisions described in the Teresa DeGuzman, DDS handbook, which may be periodically amended. I further understand that if employed by Teresa DeGuzman, DDS no representative of Teresa DeGuzman, DDS, other than the President, has any authority to modify or change my status as an employee at will and that such modifications must be in writing signed by the President. Finally, I understand that this is only an application for employment and neither an offer of or a contract of employment and no part of this application shall be construed as an offer of employment or an employment contract. The Agreement to Arbitrate accompanying this application must be read and signed in order for you to be considered for employment with Teresa DeGuzman, DDS or any of its related companies. By signing the Agreement to Arbitrate I understand that the employment at will relationship will not be altered.


Date	Name of Applicant

Agreement to Arbitrate

Because of, among other things, the delay and expense which result from the use of the court systems, Teresa DeGuzman, DDS (and its related companies, and / or their current or former employees) and I agree that any legal or equitable claims or disputes arising out o or in connection with the employment, terms and conditions of employment, or termination of employment will be settled exclusively by binding arbitration instead of in a court of law or equity. This agreement applies to all disputes involving legally protected rights (e.g., local, state, and federal statutory, contractual or common law rights) regardless of whether the statute was enacted or the common law doctrine was recognized at the time this agreement was signed. I understand that this agreement does not limit my ability to complete any external administrative remedy (such as with the EEOC).

The arbitration proceedings shall take place in Sacramento, California in accordance with the National Rules for Resolution of Employment Disputes (National Rules) of the American Arbitration Association (AAA) in effect at the time that the demand for arbitration is made. There will be one arbitrator chosen by mutual agreement of the parties. If, within thirty days after the employee notifies the employer of an arbitration dispute and no arbitrator has been chosen, then an arbitrator will be chosen by AAA pursuant to its National Rules. The arbitrator shall coordinate and limit as appropriate all pre-arbitration discovery (e.g., document production, information requests, depositions). The arbitrator shall issue a written decision and award (if any) stating the reasons for the decision and award. The decision shall be exclusive, final and binding on both parties, their heirs, executors, administrators, successors and assigns, and may be entered and enforced in any court of competent jurisdiction. The employee is entitled to representation by an attorney throughout the proceedings at his or her own expense. The costs and expenses of the arbitration shall be borne evenly by the parties, unless otherwise awarded by the arbitrator in the final, written decision.

I understand that by signing this agreement that I am agreeing to substitute one legitimate dispute resolution form (arbitration) for another (litigation), thereby waiving any right to have my dispute resolved in court. This substitution involves no surrender, by either party, of any substantive statutory or common law benefits, protection, or defense.

I understand that if I should become employed by Teresa DeGuzman, DDS, or its related companies, such employment is conditioned upon this Agreement and I understand that this Agreement must be read and signed in order for me to be considered for employment with Teresa DeGuzman, DDS or its related companies. The parties agree that this is not intended to add to, create, or imply any contractual or other right of employment. The parties employment relationship is at will, and no other inference is to be drawn from this Agreement.

Employee

Date