APPLICATION FOR EMPLOYMENT

Position Applied for:
Date Available
Schedule Desired

Full TimePart TimeTemporary
List any days/hours you are unable to work:
Rate of Pay Desired:
Do you have a drug related criminal conviction, other than simple possession of marijuana?

YesNo
If yes, explain:
It is our policy that smoking not be permitted in the pharmacy work area. Do you object to this policy?

YesNo

Job References

List only persons we may contact regarding your work experience (Ph# included)
1. Name
Work Location
Job Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
2. Name
Work Location
Job Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
3. Name
Work Location
Job Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
4. Name
Work Location
Job Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Applicant: Read and Sign Below

The information provided by me in this application for employment is true and complete to the best of my knowledge. I understand that if I am employed, and false statement will be considered as cause for possible dismissal.
APPLICANT SIGNATURE
DATE

MonthDayYear
Date
Richmond Apothecaries Inc, doing business as Bremo Pharmacy is committed to implementing the Americans with Disability Act (ADA The ADA prohibits discrimination against qualified individuals with disabilities. The term "qualified individual with a disability" as defined by the ADA means an individual with a disability who with or without a reasonable accommodation, can perform the essential functions of the employment position desired.

A job description has been provided and I acknowledge that I have reviewed it and disclosed below any disability or limitations that would need to be accommodated in order for me to carry out the duties listed in that job description.
APPLICANT SIGNATURE
DATE

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Date
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