Employment Application

Thank you for your interest in and application for employment with GRX Holdings, LLC We are an equal opportunity employer and give employment and promotional consideration without regard to race, color, creed, sex (including pregnancy), religion, marital status, age, national origin or ancestry, physical or mental disability, medical condition, genetic information, gender identity or expression, sexual orientation, military status, or any other consideration made unlawful by federal, state, or local laws. We seek applicants for employment who are dedicated, hardworking and seeking fulfilling employment. In return, GRX Holdings, LLC offers competitive income, an excellent work environment and the opportunity to grow with the company.

Name*

First NameMiddle InitialLast Name

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Email Address

Are you legally able to work in the United States?*

YesNo

Have you ever been convicted of a crime other than a traffic violation?*

YesNo

Position for which application is being made (be specific):*

Are you at least 18 years old?*

YesNo

I am available to work: (check all that apply)*

Date Available:*

Date

Expected Compensation*

Highest Level of Education Attained:*

Major Field of Study*

Last Year Completed*

1234

Did you graduate?*

YesNo

School Name*

School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Second Highest Level of Education Attained:

Major Field of Study*

Last Year Completed*

1234

Did you graduate?*

YesNo

School Name*

School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Third Highest Level of Education Attained:

Major Field of Study*

Last Year Completed*

1234

Did you graduate?*

YesNo

School Name*

School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Education Attained:

Major Field of Study*

Last Year Completed*

1234

Did you graduate?*

YesNo

School Name*

School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Name

Job Title

Employment Start

Date

Employment End

Date

Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Starting Compensation

Ending Compensation

Supervisor's Name

Reason for Leaving:

Description of Duties and Responsibilities (include promotions and advancements):

Employer Name

Job Title*

Employment Start*

Date

Employment End

Date

Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Starting Compensation

Ending Compensation

Supervisor's Name*

Reason for Leaving:

Description of Duties and Responsibilities (include promotions and advancements):*

Employer Name

Job Title*

Employment Start*

Date

Employment End

Date

Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Starting Compensation

Ending Compensation

Supervisor's Name*

Reason for Leaving:

Description of Duties and Responsibilities (include promotions and advancements):*

Name*

Address

Street Address

Street Address Line 2

CityState / Province

Phone Number*

Years Acquainted*

Name*

Address

Street Address

Street Address Line 2

CityState / Province

Phone Number*

Years Acquainted*

I certify that the above information is true and correct and give authorization for investigation of all statements and information contained in this application, my resume, other documents or verbally obtained during an employment interview. I voluntarily consent to allow GRX Holdings, LLC, or any of their representatives or agents to check my references by contacting any persons, company or governmental entity they deem to be an appropriate reference. I understand the reference questions may pertain to my personal or educational background, work experience, character and behavior. I understand my employment is subject to satisfactory verification of this information and agree that deliberate falsification of this document or significant omissions shall be grounds for employment consideration disqualification or dismissal from employment, if discovered at a later date. I also realize that company policies, procedures, practices or statements made during an interview or employment do not create an employment contract by implication or otherwise. I further understand and agree that my employment is for no definite period of time and may, regardless of time and manner, be terminated by the company or myself with or without cause or previous notice.

Signature of Applicant*

DATE*

Date

This application is valid only for 60 days frm the date singed/dated above.

Please verify that you are human*

Employment Application

General Information

Employment Desired:

Education

Employment History

References

Please read the following statements, ask any questions, and sign below.