APPLICATION FOR EMPLOYMENT
Applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.
SECTION I
Date of Application _____________________________________
Name ____________________________________________________ Soc. Sec. # ______________________
Last First Middle
Address________________________________________________________________________________________
Street City State Zip Code
Telephone # (____) ______________________________ Cell/Beeper # (____)_____________________________
Position Applied for ______________________________________________________________________________
Are you able to meet this company’s attendance requirements for this job? _____ Yes _____ No
Please give date you will be available for work ________________________________________________________
What is the salary range or hourly rate you desire? $________________________per _____________________
Please indicate your job referral source(s) and provide the name(s) of the source(s):
_____ Employee _______________________________________________
_____ School _______________________________________________
_____ Job Fair _______________________________________________
_____ Advertisement _______________________________________________
_____ Government Agency ______________________________________________
_____ Staffing Agency _______________________________________________
_____ Walk-in _______________________________________________
_____ Other _______________________________________________
Please indicate the type employment you desire:
____Full Time ____Part Time ____Seasonal ____Temporary ____Educational Co-Op or Apprentice
Have you previously submitted an application to this company? _____ Yes _____ No
If yes, please list dates and positions for which you applied. ________________________________________________________________________________________________
Have you previously worked for this company? _____ Yes _____ No
If yes, please furnish dates and positions held.
________________________________________________________________________________________________
If hired, can you furnish proof that you are eligible to work in the United States? _____ Yes _____ No
Can you furnish a work permit if required for workers under the age of 18? _____ Yes _____ No
If no, please explain _______________________________________________________________________________
Will you work overtime and/or weekends if required for this position? _____ Yes _____ No
If no, please explain_______________________________________________________________________________
Will you travel if the job requires you to do so? _____ Yes _____ No
If no, please explain _______________________________________________________________________________
EMPLOYMENT HISTORY (Begin information with your most recent employer.)
Employer______________________________________________________ Phone # (___) ___________________
Address, City, State, Zip Code______________________________________________________________________
Dates Employed __________to__________ Starting Wage ________per____ Final Wage __________per _____
Job title_________________________________________ Supervisor ____________________________________
Work performed ________________________________________________________________________________
Why did you leave? ______________________________________________________________________________
What did you like most about this job? ______________________________________________________________
What did you like least? __________________________________________________________________________
May we contact this employer for a reference? _____ Yes _____ No
Employer______________________________________________________ Phone # (___) ___________________
Address, City, State, Zip Code _____________________________________________________________________
Dates Employed ___________to___________ Starting Wage______ per _____ Final Wage _________per______
Job title__________________________________________ Supervisor ___________________________________
Summarize work performed _______________________________________________________________________
Why did you leave? ______________________________________________________________________________
What did you like most about this job? ______________________________________________________________
What did you like least? __________________________________________________________________________
May we contact this employer for a reference? _____ Yes _____ No
Employer______________________________________________________ Phone # (___) ___________________
Address, City, State, Zip Code _____________________________________________________________________
Dates Employed ___________to___________ Starting Wage______ per _____ Final Wage _________per______
Job title__________________________________________ Supervisor ___________________________________
Summarize work performed _______________________________________________________________________
Why did you leave? ______________________________________________________________________________
What did you like most about this job? ______________________________________________________________
What did you like least? __________________________________________________________________________
May we contact this employer for a reference? _____ Yes _____ No
Employment History (continued)
If there are gaps in your employment history, please explain, except for health reasons, such as personal illness, injury or disability. ______________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been fired from a job or asked to resign? ______ Yes ______ No
If yes, please explain circumstances. __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list any special training, skills, certificates or licenses that may qualify you for the position for which you are applying.____________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please indicate all computer skills and years of experience. Please name type of software.
____ Word Processing ________________________________________ Years ________
____ E-Mail ________________________________________________ Years ________
____ Internet _______________________________________________ Years ________
____ Spreadsheet ____________________________________________ Years ________
____ Presentation ____________________________________________ Years ________
____ Other _________________________________________________ Years.________
____ Other _________________________________________________ Years ________
Do you belong to a job-related organization ( i.e., trade, professional group)? _____ Yes _____ No
If yes, please list below.( Do not list organizations that may reveal race, color, religion, sex, national origin, age, mental or physical disabilities, veteran / reserve, national guard or any other protected status.)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you earned special recognition in past employment, such as for project accomplishments or awards?
_____ Yes _____ No If yes, please explain. ____________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Do you have supervisory experience, or have you ever held a position in which you directed the work of others?
_____ Yes _____ No If yes, please explain. ____________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________
Please furnish any other job-related information you wish to share.__________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
EDUCATIONAL BACKGROUND
Please furnish information beginning with your most recent educational experience.
Name of School including City and State Yrs Completed Certificate Received GPA Major
_________________________________ ____________ ________________ ____ ________
_________________________________ ____________ ________________ ____ ________
_________________________________ ____________ ________________ ____ ________
_________________________________ ____________ ________________ ____ ________
REFERENCES
Please list business references. If you do not have business / work references, then list school or personal references. Do not list any relatives.
Name Title Relationship Telephone # # of yrs known
____________________________ _________ _________ __________ _____________
____________________________ _________ _________ __________ _____________
____________________________ _________ _________ __________ _____________
IMPORTANT – PLEASE READ
I certify that all information I have provided within or attached to this application is true, correct and accurate. I understand that any information provided by me that is discovered to be false, incomplete or misrepresented in any respect will be sufficient cause to eliminate me from further consideration for employment, or may result in immediate termination from the employer’s service if discovered after hire.
I authorize the employer, its representatives, employees or agents to contact and obtain information from all references, employers, government and public agencies, licensing authorities and educational institutions and to verify the accuracy of the information I have provided in or attached to this application, résumé or interview. I waive any and all rights and claims I may have regarding the employer, its agents, employees or representative for seeing, obtaining and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing information about me.
I understand that this employer is an EEO employer who does not lawfully discriminate in employment and that no question on this application is used for the purpose of limiting or eliminating an applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.
If hired, I agree to conform to the company’s rules and regulations. I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the company. I understand that no company representative, other than its President / CEO, and then only in writing and signed by the President / CEO, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.
I understand that this application is current for 30 days from the Date of the Application entered on Page 1. To be considered for employment after that time period, I will have to complete another application.
I understand that if I am hired, I will be required to provide proof of my identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form within three (3) working days after hire.
I certify that I have read, understand and accept all the terms of the above applicant information.
Signature of Applicant _______________________________________ Date ____/____/____
SECTION II
Please respond to the following:
Have you been convicted of a felony? _____ Yes _____ No
If the answer is yes, please furnish details of the conviction, offense, location, date and sentence.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you been convicted of any misdemeanor? _____ Yes _____ No
If the answer is yes, please furnish details of the conviction, offense, location, date and sentence.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you presently formally charged with committing a criminal offense? (Do not include any traffic violations, juvenile offenses or military convictions, except by general court-martial) _____ Yes _____ No
If the answer is yes, please furnish details of the conviction, offense, location date and sentence.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever knowingly used any controlled substances other than those prescribed to you by a physician? _____ Yes _____ No
If the answer is yes, please furnish details.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been bonded? _____ Yes _____ No
I authorize my employer, _____________________________, to make any inquiry necessary of courts and law enforcement agencies for possible pending charges or convictions.
I understand that information furnished or recovered as a result of any inquiry will not necessarily preclude employment, but will be considered as part of an overall evaluation of my qualifications.
I understand that any false information or omission of information on the Employment Application or this questionnaire will jeopardize my position with respect to employment.
_____________________________________________ ______/______/______
Signature of Applicant Date
SECTION III (FOR PHARMACISTS, PHARMACY TECHNICIANS AND PHARMACY INTERNS ONLY)
Please respond to the following:
Please insert as applicable:
Pharmacist license number: ______________________________________________________________
Pharmacy technician license, registration and/or certification number: _________________________
Pharmacy intern license, registration and / or certification number: ____________________________
HIPAA-mandated National Provider Identifier number: _____________________________________
Have you ever been the subject of a license, registration (i.e., DEA, State controlled substances registration) or certification (i.e., PTCB) disciplinary action? ____yes _____ no_____ not applicable
If the answer is yes, please furnish details of the disciplinary action. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are any charges currently pending against your license, registration or certification?
_____ yes _____ no _____ not applicable
If the answer is yes, please furnish details of the pending charges. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Is your license or certification currently active and in good standing?
_____ yes _____ no _____ not applicable
If the answer is no, please explain, including anticipated date that license or certification will be active.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been excluded by any government authority (i.e., U.S. Department of Health and Human Services Office of Inspector General) from participation in any federal (i.e., Medicare) or state (i.e., Medicaid) health care program? _____ yes _____ no
If the answer is yes, please furnish details of the exclusion, including when the exclusion was removed.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been excluded by any commercial insurance plan or pharmacy benefit manager from participation in a provider network or otherwise from providing services to program beneficiaries?
_____ yes _____ no
If the answer is yes, please furnish details of the exclusion, including when the exclusion was removed.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SECTION III, continued
Have you ever been named as a defendant in a professional liability lawsuit? _____ yes _____ no
If the answer is yes, please furnish details of the lawsuit.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever been denied any policy of professional liability insurance? _____ yes _____ no
If the answer is yes, please furnish details.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
SECTION 1V
Authorization For Release of Information
I, the undersigned applicant do hereby authorize my employer, ______________________________________, to make inquiries as a part of the pre-employment process. These inquiries may include, but are not limited to the following:
· Inquiries to previous employers and / or other references.
· Depending on the position applied for, a credit check.
· A criminal record search.
I release and hold harmless any individual, firm, or other organization, from any liability or action resulting from release of information as may be requested by my employer, ________________________________________, as part of the pre-employment process.
Applicant: ______________________________ ______________________________
Print Name Signature
Witness: _______________________________ ______________________________
Print Name Signature
Date: ______/______/______
