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Application for Employment
To Applicant: We appreciate your interest in Hometown Pharmacy. A record of your work history will aid in considering you for a position. A resume may be attached but does not substitute for any portion of this application. All persons who are hired must, by law, present acceptable evidence of their eligibility to work in the United States.
Personal Information
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E mail Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number (Cell Phone)*

Area CodePhone Number
Are you legally eligible for employment in the U.S.A.?*
Position applying for
Rate of pay expected (per hour)*
Would you work Full Time or Part Time*
Specify days and hours available (if part time or Seasonal)
How quickly would you be able to start, if hired?
List any skills or qualifications, which you feel, would especially fit you for work with our organization?
Education
High School
Date Graduated

MonthDayYear
Date
College
Date Graduated

MonthDayYear
Date
College Degree
Major
List other schools attended with completion dates
List all credentials and licenses held with date issued and certificate number
Employment History

(List all present and past employment starting with the most recent. Indicate which employers you do not want us to contact for references)
Employer #1
Dates of Employment
Address/Location
Supervisor
Position
Reason for leaving
Rate of Pay
Can we contact them for a reference
Employer #2
Dates of Employment
Address/Location
Supervisor
Position
Reason for leaving
Rate of Pay
Can we contact them for a reference
Employer #3
Dates of Employment
Address/Location
Supervisor
Position
Reason for leaving
Rate of Pay
Can we contact them for a reference
Personal References
Name #1
Relationship
Phone Number

Area CodePhone Number
Name #2
Relationship
Phone Number

Area CodePhone Number
Name #3
Relationship
Phone Number

Area CodePhone Number
Office Skills
List all office and computer skills. Note typing speed and all software programs you skilled in
Have you ever been convicted of a crime and the record not been sealed or expunged by the courts (excluding minor traffic violations)?*
If yes please provide information
Upload Resume (if available)

Cancelof
I certify that all of the information herein is true and correct. I understand and agree that if employed, false, misleading or incorrect statements or material omissions on this application may be sufficient cause for termination at any time and that the Hometown Pharmacy shall not be liable in any respect if my employment is terminated. I acknowledge that employment with the Hometown Pharmacy is "at will" and either the Hometown Pharmacy or I may terminate the employment relationship at any time, with or without cause. I authorize the Hometown Pharmacy or its agent(s) to investigate all information on this application. I further authorize the Hometown Pharmacy or its agent(s) to make investigative inquiries and obtain reports such as motor vehicle driving record, criminal background check, or any other inquiries or reports as the Hometown Pharmacy deems necessary.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Should be Empty:

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Personal Information

Education

Employment History

Personal References

Office Skills