* Required Information
Application For Employment
Last Name
*
First Name
*
Middle Name
Birth Date
*
Phone Number
*
Present Address
*
How Long
Social Security No.
*
Email
*
If under 18, please list age
Position Applied for
*
- Please select -
Pharmacist
Pharmacist In charge
Pharmacy Technician
Pharmcy Technician Trainee
Pharmay Technician Trainee ( Externiship )
Delivery Driver
Customer Service Associate
Pharmacy Marketing Associate
Salary Desired
*
How many hours can you work weekly
Employment desired
*
Fulltime Only
Part Time Only
Full or Part Time
When Available to work
*
Available to Work
*
Monday
*
Tuesday
*
Wednesday
*
Thursday
*
Friday
*
Saturday
*
Sunday
*
Holiday
*
Education
High School
Name of School
Address
No of Years Completed
Major Degree
College
Name of School
Address
No of Years Completed
Major Degree
Post Graduate
Name of School
Address
No of Years Completed
Major Degree
Professional School
Name of School
Address
No of Years Completed
Major Degree
Have you ever been convicted of a crime?
Yes
No
Explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation
DO YOU HAVE A DRIVER’S LICENSE?
Yes
No
What is your means of transportation to work?
Driver’s license number
State of issue
Expiration date
Have you had any accidents during the past three years?
Yes
No
How many?
Have you had any moving violations during the past three years?
Yes
No
How many?
Please list two references other than relatives or previous employers
Name
Position
Company
Address
Telephone
Name
Position
Company
Address
Telephone
Are you now or ever been a member of The National Guard?
Yes
No
Have you ever been in Armed Forces?
Yes
No
Summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying
Work Experience
Please list your work experience for the past five years beginning with your most recent job held.
I.
Name of Employer
Address
Phone number
Name of last supervisor
Dates
From
To
Pay or Salary
Start
End
Reason for leaving (be specific)
Please list job you held, duties performed, skills used or learned, advancements or promotions received while you worked at this company
II.
Name of Employer
Address
Phone number
Name of last supervisor
Dates
From
To
Pay or Salary
Start
End
Reason for leaving (be specific)
Please list job you held, duties performed, skills used or learned, advancements or promotions received while you worked at this company
III.
Name of Employer
Address
Phone number
Name of last supervisor
Dates
From
To
Pay or Salary
Start
End
Reason for leaving (be specific)
Please list job you held, duties performed, skills used or learned, advancements or promotions received while you worked at this company
IV.
Name of Employer
Address
Phone number
Name of last supervisor
Dates
From
To
Pay or Salary
Start
End
Reason for leaving (be specific)
Please list job you held, duties performed, skills used or learned, advancements or promotions received while you worked at this company
May we contact your present employer?
Yes
No
Did you complete this application yourself?
Yes
No
Explain
Resume
CV
Letter of Recommendation
References
Driver’s license
Social Security Card
Google Documents Links (separate with comma)
Certification & Authorization
The above information is true and correct. I understand that, in the event of my employment, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize the Potential Employer to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Potential Employer. I will hold the Potential Employer, and my former employer, harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize the Potential Employer to obtain any credit and consumer check. I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Potential Employer is intended to create an employment contract between myself: and the potential employer, and that my employment could be terminated only for cause. On the contrary, I understand and agree that, if hired, my employment will be terminable at will, and may be terminated by me or the potential employer at any time, and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9.
I give permission to Designees of the Host Agency on behalf of PrimeCare Pharmacy to conduct a criminal background check to investigate my criminal history and driving record. I understand that the scope of this investigation will be limited to a criminal history background report and/or driving record report. The information obtained from the criminal history background report will remain confidential and will be used by PrimeCare Pharmacy, the Host Agency, and clients of the Host Agency to whom I could potentially provide service, for consideration of entering into a contract with me for the purchase of services. I understand that the results from my criminal background check may result in my ineligibility to contract with a potential employer because of Medicaid Regulations. Representative(s) of the Host Agency administration will make this determination. In addition, I understand that any falsification or willful omission of fact made in connection with the criminal background check may be sufficient grounds for rejection of my eligibility to contract with the Host Agency. This consent shall be in effect for one year from the date of signature. I give permission for the Host Agency or designee, to release the results of my Criminal Background Check and Driver's Check to Primecare Pharmacy, individuals who will be direct consumers of my services, and individuals who are guardians or family members of direct consumers of my services.
EMPLOYEE AGREEMENT AND CONSENT TO DRUG AND/OR ALCOHOL TESTING
I hereby agree, upon a request made under the drug/alcohol testing policy of PrimeCare Pharmacy , to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under company policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have the Company and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to the Company and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize the Company to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.
I understand that only duly-authorized Company officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities.
I will hold harmless the Company, its company physician, and any testing laboratory the Company might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might ar ise as a result of the drug or alcohol test, even if a Company or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless the Company, its company physician, and any testing laboratory the Company might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.
This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.
I understand that the company will require a drug screen and/or alcohol test under this policy whenever i am involved in an on-thejob accident or injury under circumstances that suggest possible involvement or influence of drugs or alcohol in the accident or injury event, and i agree to submit to any such test.
Signature of applicant
Date
Applicant’s Name – Printed
Submit