eAssist Account Manager Application
* Required

eAssist is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.

Contact Information
First Name *
Middle Name
Last name*
Email address *

Password *
Retype Password *
Mobile phone *
Address *
City *
State *
Zipcode *
Country *
Skill Set
What salary or rate of pay do you expect to receive if employed? *
Date of availability to begin employment *
How many years of dental experience have you had? *
How many years of FRONT OFFICE dental experience have you had? *
Which language(s) are you comfortable communicating in?
(English, Spanish, French, etc)
How many day time hours do you have available to work for us next week--if hired?
How many evening hours do you have available?
How fast can you type? *
Have you ever applied to work with eAssist before?
(If yes, please give date)
Are you legally authorized/eligible to work in the United States?
(Proof of eligibility will be required upon offer of employment)
Are you over the age of 18 years?
(If no, you may be required to provide authorization)
Have you ever been convicted of a felony? *
(A conviction will not necessarily be a disqualifying event. If Yes, please explain)
Is anyone related to you working with eAssist? *
(If yes, please give name and relationship to you)
How did you hear about this opportunity? *
Interested in a full or part-time position? *
What dental office management software are you competent in? *
What internet browser are you most comfortable using *
Do you plan on using a Mac or PC computer while working for eAssist? *
Please describe your formal educational experiences *
(Please select all that apply. If you are a college graduate, please write down in "other" what kind of degree you have earned and from which university.)
Dental Front Office Skill Set *
(Please select all that apply)
How would you rate your computer skill level? *
(Please select all that apply)
Are you currently employed?
Current Employer (n/a if not applicable)
Do you currently or have you ever worked for an office that is an eAssist client?
When could you start?
Internet Broadband Specifics
Who is your internet service provider?*
Type of internet connection?*
click here to run an internet speed test.
Once your speed test has completed please take a screen shot of your test and upload it in the provided area.
What were the ping results of your internet speed test?*
How fast is your internet DOWNLOAD connection at home? *
How fast is your internet UPLOAD connection at home? *
Upload the screen shot.
Education, Honors, and References
Please indicate any academic honors, scolorships, office held, etc
(Do not list any which reflect your race, color, religion, gender, national origin, age, disabilities or veteran status)
Describe any specialized vetting, apprenticeships, licenses or skills
Please describe ALL DENTAL OFFICE employment history. *
(Please include the name of the dentist offices, employment dates, salaries, phone numbers, description of duties, and reasons for leaving. Also include whether or not we may contact specific employers.)
List 3 professional references *
(Please include names, addresses, phone numbers, relationship / occupation, and years known.)
Name Address Phone number Occupation Years
Electronic Signature *
APPLICANT ACKNOWLEDGEMENT 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 falsification, misrepresentation or omission or any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery. I understand that submission of any application does not guarantee employment. I further understand that, should an offer of employment be extended by eAssist (hereinafter referred to as “eAssist”) that such employment with eAssist is at will, for no specific duration and may be terminated by either eAssist or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of eAssist or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of eAssist except the President has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the President of eAssist. In consideration for employment with eAssist, if employed, I agree to conform to the rules, regulations, policies and procedures of eAssist at all times and understand that such obedience is a condition of employment. I understand that due to the nature of eAssist business, attendance and punctuality are considered essential requirements of every job at eAssist and that poor attendance or tardiness will result in disciplinary action. I understand that if offered a position with eAssist, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed. I herby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to eAssist and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information. I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.


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