Employment Application
Thank you for your interest in Tallapoosa Drugs! Please fill out the form below to submit your application for employment.
Personal Information
Name
First Name
Last Name
Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Date at which you started living at your current address
-
Month
-
Day
Year
Date
Gender
Male
Female
What is your race?
Native American/Alaskan Native
Hispanic
White
African American
Asian/Pacific Islander
Other
Are you legally authorized to work in the United States? (If hired, verification will be required consistent with federal law)
Yes
No
Are you 16 years of age or older?
Yes
No
Part of our pre-employment screening involves a criminal background check. We require your authorization and release to conduct this check. If hired, will you authorize us to conduct a criminal background check?
Yes
No
Print Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Position applying for:
Part-Time
Full-Time
Either
Position applying for:
Cashier
Photo
Delivery
Technician
Manager
RPh
Starting out, what do you expect to earn on an hourly basis?
If hired, when would you be available to start?
-
Month
-
Day
Year
Date
Will you be able to work holidays?
Yes
No
Are you available to work any day and time of the week?
Yes
No
If no, what days and times:
Are you now, or have you ever been known by any other name, or have you changed your name (first or last)?
Yes
No
If yes, what names have you been known by:
Other than your current address, have you lived at any other address in the past 5 years?
Yes
No
Tell me about yourself
I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
*
I understand
Education
Highest level of education completed
Highschool grades
9
10
11
12
Course of study
General
Technical
College Prep
Current GPA
College
1
2
3
4
References
Two work related references – not family members or friends
Reference Name #1
First Name
Last Name
Reference Name #1 Phone Number
Please enter a valid phone number.
Reference Name #2
First Name
Last Name
Reference Name #2 Phone Number
Please enter a valid phone number.
Work History
Employer name
Phone Number
Please enter a valid phone number.
Reason for leaving
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Employer name
Phone Number
Please enter a valid phone number.
Reason for leaving
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
I certify that I have read and fully completed this application and that the information contained herein is correct to the best of my knowledge. I understand that any. omission or false information is grounds for dismissal. I authorize the references listed on this application to give you any information concerning my previous employment and pertinent information they may have: personal and otherwise.
Yes
Print Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: