* = Required Information
Hr. Mgr.  HIRED / NOT HIRED / TEMP. JOB / PROBATION TIME
We are committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of actual or perceived age, sex, sexual orientation, race, color, creed, religion, familial status, ethnicity, national origin, alienage or citizenship, disability, marital status, military or veteran status, or any other legally recognized protected basis under federal state or local laws, regulations or ordinance. Applicants with a disability may be entitled to reasonable accommodations under terms of the Americans with Disabilities Act and certain state or local laws. A reasonable accommodation is a change in the way things are normally done which will ensure an equal employment opportunity without imposing undue hardship on the Pharmacy. Please inform a Company representative if you need assistance completing any forms or to otherwise participate in the application process. This application will remain active for 60 days, after 60 days you must reapply for further consideration.
RX TECH RX CASHIER RXDRIVER MARKETING OTHER
Street
City
State
Zip
(If hired, verification will be required consistent with federal law)
YES NO
YES NO
YES NO
Employee pharmacy walk in Other
YES NO
EMPLOYMENT AVAILABILITY

SUN
MON
TUE
WED
THU
FRI
SAT
LIMITATION ON AVAIBILITY MAY LEAD TO PAY CUT /HOURS CUT /TERMINATION  SIGN
EDUCATION
High School or GED
9 10 11 12
YES NO
College or University
9 10 11 12
YES NO
Other (Specify)
9 10 11 12
YES NO
YES NO
FULL PART NONE
*Beginning with the most recent employment, list the last four employer (including military service) or cover at least a seven year period, whichever is longer. Use separate sheet if necessary.
(1)
Base Salary or Wage
(2)
Base Salary or Wage
(3)
Base Salary or Wage
(4)
Base Salary or Wage
YES NO
YES NO
YES NO
REFERENCES
List two professional references familiar with your work ability (exclude relatives)
(1)

Street

City

State

Zip
(2)

Street

City

State

Zip
READ CAREFULLY AND SIGN
PLEASE READ THESE STATEMENTS OVER CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING AT THE BOTTOM
I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.
 Initial *
I understand, where permissible under applicable state and local law, I may be subject to a PRE & POST -employment drug test (WITH OR WITHOUT ADVANCE NOTICE) after receiving a conditional offer of employment, and must receive a negative result before & after being permitted to commence work with the pharmacy.
 Initial *
I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical examination after receiving a conditional offer of employment, and must meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with the Pharmacy. & may pull DRIVER LICENSE HISTORY (IF APPLICABLE...) PRE & POST EMPLOYMENT.
 Initial *
I hereby certify that the information given by me is true in all respects. I authorize the Pharmacy and its representatives to contact my prior employers and all others for the purpose of verification of the information I have supplied and release same from any liability resulting from the information released. I authorize employers, schools and other persons named on this application to provide any information or transcripts requested.
 Initial *
I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
 Initial *
I understand that no representation, whether oral or written, by any representative or agent of the Pharmacy, at any time, can constitute an implied or expressed contract of employment. I further understand no representative or agent of the Pharmacy, has the authority to enter into an agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other terms or condition of employment other than in a document signed by the Director of Human Resources or his/her authorized representative.
 Initial *
I certify, under penalty of perjury, that all of the above information is true and complete, and I understand that any falsification or omission of information may result in denial of employment or, if hired, may result in termination regardless of the time lapse before discovery.
 Initial *
Note: An offer of employment is conditional upon complying with the Pharmacy requirements including, but not limited to signing a Consent to Conduct an Investigation.
MY SIGNATURE IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE STATEMENTS INCLUDING BACKGROUND CHECK FOR EMPLOYMENT.
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