GDD Pharmacy Services Inc. Employment Application

Employment Application GDD Pharmacy Services Inc. is an equal opportunity employer. Applicants will be considered regardless of race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status. Equal access to the hiring process, services, and employment is available to all individuals. Applicants requiring accommodations to the application and/or interview process should contact the Human Resource Representative. Each question should be answered completely and accurately. No action will be taken on this application until all questions have been answered and the application has been signed and dated. Verification of eligibility to work in the U.S. will be required if an employment offer is made.
Full Name*

First NameMiddle NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*

Confirmation Email
Position applying for:

PharmacistPharmacy technicianCashierDelivery DriverOther
If Technician or cashier, which pharmacy would you like to be considered to work at?(Location and schedule will be discussed at interview):

Pine grove PharmacyGood Day Pharmacy or Cumberland ApothecaryHarrisburg Pharmacy or See-Right PharmacyAny Harrisburg/Mechanicsburg area pharmacy East or West ShoreI'm flexibleOther
If Delivery driver, which area are you applying for:

Harrisburg East and West Shore areasPine Grove and Schuylkill county areaCarlisle and Chambersburg areaLewistown areaAllentown areaLancaster areaYork and Hanover areaI'm flexibleOther
If applying to be Part Time delivery driver, when are you available? Check all that apply:

Early afternoonsLate afternoonsEarly eveningsEveningsSaturdaysI'm flexible
Hourly Wage expectations*
Hourly wage expectation*
e.g. $10
Referral source
Are you over the age of 18?*

YESNO
Are you eligible to work in the United States?*

YESNO
Are you fluent in a foreign language?*

YESNO
If yes, what language(s)?
Are you currently employed?*

YESNO
If Yes, will you be keeping your present job too?
Are you currently on "lay off" status and subject to recall?

YesNo
Date available for work*

MonthDayYear
Are you available to work?*

Full timePart timeCollege student schedule (Summers and breaks)
Have you applied here before?*

YESNO
If yes, give date:*
Do you have a valid drivers license?

YesNo
Do you have reliable transportation to work?

YesNo
Have you been convicted of a felony/misdemeanor (other than traffic violations)?*

YESNO
If so, provide the location, date and result/outcome for each conviction:*
EDUCATION
Highest level of education completed:*

Please complete the appropriate sections

Rows	Name & Location of School	Number of Years Attended	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

WORK HISTORY Please list your 1-3 most recent employers, list the most recent first:
1. Employer
Employer's Name (Most current)*
Location of business-City & State*
Your job title*
May we contact this employer?*

YESNO
Supervisor's name*
First and Last Name
Start date*

MonthDayYear
End date

MonthDayYear
Wages START:*
Salary or Hourly*
Wages END:*
Salary or Hourly*
Work performed:*
Reason for leaving*
2. Employer 2
Employer's Name (Second most recent)
Location of business-City & State
Your job title
May we contact this employer?

YESNO
Supervisor's name
First and Last Name
Start date

MonthDayYear
End date

MonthDayYear
Wages START:
Salary or Hourly
Wages END:
Salary or Hourly
Work performed:
Reason for leaving
3. Employer 3 (may leave blank)
Employer's Name (Third most recent)
Location of business-City & State
Your job title
May we contact this employer?

YESNO
Supervisor's name
First and Last Name
Phone number

Area CodePhone Number
Start date

MonthDayYear
End date

MonthDayYear
Wages START:
Salary or Hourly
Wages END:
Salary or Hourly
Work performed:
ADDITIONAL INFORMATION
Do you have a U.S. military service record?*

YESNO
If yes, branch of service
If yes, Discharge year and rank
List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)
List any additional information you would like us to consider:
REFERENCES List 2-3 professional references, that you have known for at least one year. List at least one previous supervisor.
1. Full Name*

First NameLast Name
Company*
Best phone number to reach them*

Area CodePhone Number
Years acquainted*
Relationship*
2. Full Name*

First NameLast Name
Company*
Best phone number to reach them*

Area CodePhone Number
Years acquainted*
Relationship*
3. Full Name

First NameLast Name
Company
Best phone number to reach them

Area CodePhone Number
Years acquainted
Relationship
AUTHORIZATION I understand that GDD Pharmacy Services Inc. is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination, if employed. I authorize GDD Pharmacy Services Inc. to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, credit history, driving record, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to GDD Pharmacy Services Inc.. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original. Pre-employment testing may be required (drug testing, background checks, physical examinations, motor vehicle checks).Testing may be applicant or employer paid based on the employer.I understand that any offer of employment may be withdrawn if drug tests are positive and/or if a condition is discovered for which no reasonable accommodation can be made. I understand that this application is current for 60 days. At the conclusion of this time, if I have not heard from GDD Pharmacy Services Inc. and still wish to be considered for employment, it will be necessary to complete a new application. I understand that if hired, employment is at-will, regardless of the employer, and may be terminated by myself, the employer or GDD Pharmacy Services Inc.at any time, with or without cause or notice, for any reason or no reason.
By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree
You must agree to accept the terms of the document in order to submit an application.
Type signature*
Date*

MonthDayYear
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