Remote Retail Pharmacy Technician Agreement

REMOTE PHARMACY TECHNICIAN

Agreement for a remote pharmacy technician, complete this form.
Your Name

First NameLast Name
Position
The person signing our agreement acknowledges that he/she is an authorized signer for the company.
Pharmacy Operating Name
Company Legal Name (for inclusion in agreement)
Pharmacy NABP #
Insert your pharmacy NABP #
Pharmacy Phone Number
Format: (000) 000-0000.
Pharmacy Location

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacy Management System Used
Tell us when you may need a remote pharmacy technician. Please indicated days of the week and times of day.
Staffing available based on demand and schedule and will be a 2 hour commitment.
Start Date Request

MonthDayYear
2 digit month, 2 digit day, 4 digit yearTarget date for providing coverage
Enter the message as it's shown
Validate Email to Proceed to Full Staffing Agreement. The agreement will be available to review and sign following a verification step. The agreement does NOT obligate the client to use or pay for services.
Sign here acknowledging that you understand that you agree to the terms and conditions of the Remote Technician Agreement with Indispensable Health, including its Business Associate Agreement.
DateTime
Should be Empty:

REMOTE PHARMACY TECHNICIAN