Candidate Profile Form If you are searching for an Associate Dentist or Specialist opportunity, complete the Henry Schein Nationwide Dental Opportunities candidate profile form below. Personal Contact InformationFirst Name* Last Name* Email* Phone*Mobile PhoneMailing Street* Mailing City* Mailing State*SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYMailing Zip Code* Specialty InformationPrimary Dental Specialty*SelectGeneral DentistEndodontistOral SurgeonOrthodontistPediatric DentistPeriodontistProsthodontistAny SpecialtySecondary Dental SpecialtySelectGeneral DentistEndodontistOral SurgeonOrthodontistPediatric DentistPeriodontistProsthodontistAny Practice TypeDescribe any Clinical Skills*Describe any Special Skills*Languages Spoken* English Spanish Mandarin Tagalog Vietnamese Hebrew Russian French Other Specify Other Language(s)* Right / Left Handed?*SelectRightLeftAny Specialized Training? Position Type DesiredAssociate Associate Partner Partner Dental Director Dental Director Open to Ownership Opportunities Open to Ownership Opportunities Non-Clinical Non-Clinical Interest in Work with Children*SelectExclusivelySomeNot at all AvailabilityDays Notice Required*SelectImmediate10 Days30 Days60 Days90 DaysIdeal Date to Start* Personal InformationCurrently Own a Practice?*SelectYesNoLooking to Sell Your Practice?*SelectYesNo Candidate Source InformationHow Did You Hear About Us?SelectADA Career Center/websiteHenry Schein Rep (Provide Name Below)HSNDO WebsitePrevious HSNDO Candidate (Provide Name Below)Colleague/Friend (Provide Name Below)Dental School/Residency Program (Provide Name Below)Print advertising/Trade Ad (Provide Name Below)Google Search/Search engineEmailWebinar/Seminar (Provide Name Below)Henry Schein (not NDO) websiteMailing/CatalogueArticleSocial Media: Facebook, LinkedIn, Twitter (Provide Name Below)Other (Provide Name Below)Please Provide Name, If Applicable Other Recruiting ActivitiesPractices to Avoid (Please Exclude Employers)* Working with Other Recruiting Companies?*SelectYesNoPlease List Other Recruiting Companies* Restrictive CovenantsAny Restrictive Covenant?*SelectYesNoIf so, how far from?* Location DesiredState / States of Preference* AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY City / Metro Area of Preference 1* City / Metro Area of Preference 2 City / Metro Area of Preference 3 Current LicensingActive License or Student?* Active License Student State of License #1*SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYState #1 Licensing Status*SelectActiveInactiveExpiredIssuesPendingOtherState of License #2SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYState #2 Licensing StatusSelectActiveInactiveExpiredIssuesPendingOtherState of License #3SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYState #3 Licensing StatusSelectActiveInactiveExpiredIssuesPendingOtherState of License #4SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYState #4 Licensing StatusSelectActiveInactiveExpiredIssuesPendingOtherState of License #5SelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYState #5 Licensing StatusSelectActiveInactiveExpiredIssuesPendingOther Licensing (Other)If Applicable, Please Check States You Are Medicaid Credentialed AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Have You Taken Any Boards?*SelectYesNoWhat Boards Have You Taken?* Sedation Certified / Licensed?*SelectYesNoType of Sedation Detail* Disciplinary / Malpractice InformationAny Suspensions?*SelectYesNoSuspension(s) Details* Any State Disciplinary Actions?*SelectYesNoState Disciplinary Action(s) Details* Any Revocations?*SelectYesNoRevocation(s) Details* Any Malpractice Claims in the Last Five Years?*SelectYesNoMalpractice Suit Details* Current EmploymentEmployment / Student Status*SelectEmployedStudentResidentUnemployedCurrent Employer Name* Please Upload your CV*Max. file size: 50 MB. Previous EmploymentEmployer 1 Employer 1 StateSelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYEmployer 2 Employer 2 StateSelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWYEmployer 3 Employer 3 StateSelectAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY EducationDental School* Dental Graduation Year* Residency School* Residency Graduation Year* 2nd Residency School 2nd Residency Graduation Year Other Candidate InformationCitizenship Status*U.S. CitizenH1B VisaTN VisaEAD VisaOPT VisaGreen CardOtherPlease Explain Other Citizenship Status* Non-Disclosure Agreement Whereas, In order to evaluate various potential associate opportunities and/or practice purchase opportunities (hereinafter "Opportunities") the undersigned may be informed of, provided, presented and/or entrusted with various personal, business and other confidential information and documents by Henry Schein Nationwide Dental Opportunities (hereinafter referred to as "HS NDO"), a division of Henry Schein Financial Services, LLC (HSFS), its agents, and/or representatives; and Whereas, Disclosure of said confidential information, documents, and/or the names of the parties involved may result in serious economic and other consequences to the parties involved, including their agents, representatives and HS NDO; Now, therefore, the undersigned party hereby agrees as follows: Except as provided in section 4. hereinafter, not to disclose or discuss any information, documents, the names of the parties or circumstances associated with any information disclosed to the undersigned by HS NDO or the party whose information is being disclosed, unless said disclosure has been authorized in writing by HS NDO. Except as provided in section 4. hereinafter, not to disclose to anyone any ideas or concepts, information, documents, contracts, or procedures given to or discussed with the undersigned by HS NDO for the purpose of considering or entering into any agreement involving an Opportunity for which HS NDO is providing consulting services. Not to make any copies, reproductions or any other records of any information or documents presented to the undersigned for the purpose of evaluating a potential opportunity including any materials, contracts or other documents entrusted to the undersigned by HS NDO for the purpose of evaluating the Opportunity. Notwithstanding anything to the contrary contained herein or as previously prohibited, the undersigned shall be allowed to disclose to the undersigned’s legal, accounting, or other personal advisor and/or spouse any information disclosed to the undersigned without obtaining the previously mentioned prior written consent, providing that the undersigned acknowledges and agrees to accept personal responsibility for any damages incurred as the result of any subsequent disclosure of that information by the party to whom the undersigned has disclosed said information. To hold HS NDO, HSFS, and its agents and representatives harmless from any action taken as a result of the undersigned’s disclosure of said information, or the subsequent disclosure by any agent of the undersigned to who said information was disclosed. To return immediately upon request by HS NDO all materials, data, contracts, documents, or other materials entrusted to the undersigned for the purpose of evaluating the Opportunity. Not to directly or indirectly contact the owner or prospective employer whose position/opportunity is being considered, or any current or past employees or representatives of said owner or employer, without prior written authorization from HS NDO. The undersigned agrees and acknowledges that the agreements made herein shall continue after the closing of any legal transactions between the undersigned and the party whose information has been disclosed. I understand that any false, misleading or omitted information in this data form may constitute sufficient cause for rejection of my application, or if employed, grounds for dismissal. You may be required to submit to a background check and drug screen after receiving a conditional offer of employment. If you disagree, you will not be considered for employment. I further understand that employment by a dental practice may be contingent upon the results of reference checks that a dental practice may conduct for employment purposes as part of the application process. I authorize HSNDO to investigate all statements made by me during the placement process. I also hereby authorize all persons, schools, companies, corporations and organizations named in this data form (and accompanying documents, if any) and law enforcement agencies to release any information concerning my background, and I hereby release HSNDO and them from any and all claims of liability that may arise out of releasing such information. Henry Schein Nationwide Dental Opportunities will be held harmless for any misinformation provided by the Candidate or Client. In order to successfully submit this form, you must electronically sign this document. By signing this document, you accept the Non-Disclosure Agreement above. Additionally, by completing this interview and submitting this data form, you attest that all information provided is true and correct. Please add your electronic signature to this document by typing your name in the signature box below.Signature* CAPTCHA NOTE: After clicking “Submit”, your submission may take a few moments to process.