Mainline Pharmacy Employment Application
General Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SSN:
Are you legally allowed to work in the United States?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
If yes, please explain
*
Education and Training
Include Technical/ Academic Achievement and Courses
Have you obtained a high school diploma or GED?
*
Yes
No
High School Name
High School Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
College/ University
College/ University Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Diploma/ Degree
Subjects of Specialization
Please list any additional specialized courses or training
Employment History
Begin with most recent employment
May we contact your current employer?
*
Yes
No
Current Company
Current Company Name
*
Title
*
Dates Worked
*
Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please explain your job duties
*
Supervisor Name
*
Supervisor Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for leaving
*
Company 2
Company Name
Title
Dates Worked
Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please explain your job duties
Supervisor Name
Supervisor Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for leaving
Company 3
Company Name
Title
Dates Worked
Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please explain your job duties
Supervisor Name
Supervisor Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for leaving
JOB SPECIFIC INFORMATION
Desired Pharmacy Location
*
Please Select
Long Term Care
Somerset
Desired Position
*
Please Select
Cashier
Pharmacist
Technician
Desired Salary
*
Have you applied for employment with us before?
*
Yes
No
How were you referred?
*
Are you acquainted with or related to any of our employees?
*
Yes
No
If yes, please specify name and relationship
*
Have you ever been fired from or asked to leave a job?
*
Yes
No
If yes, please explain
*
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