Hereford Pharmacy Employment Application Form

Hereford Pharmacy Employment Application Form
Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Were you referred by a current employee?

YesNo
Please give the name of the employee

First NameLast Name
Are you legally eligible for work in the United States?

YesNo

Job Preferences
Position you are applying for

Cashier/Service ClerkPharmacy TechnicianPharmacist
Are you at least 18 years of age?

YesNo
You must be at least 18 years of age to apply for the position of Pharmacy Technician or Pharmacist

Please edit your response above
Schedule Preferences

Full TimePart TimeSeasonalOther
Number of Hours per Week
Desired Hourly Rate/Salary
Availability

Hereford Pharmacy is open during the week from 9:00 AM to 8:00 PM, Saturdays from 9:00 AM to 5:00 PM, and Sundays 10:00 AM to 3:00 PM
Available Start Date

MonthDayYear

Please indicate the times you are available to work

	Morning	Afternoon	Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please list any other scheduling restrictions
Will you work overtime if necessary?

YesNo

Education
High School
Name of School
City & State
Did you earn a diploma?

YesNo
Undergraduate College/Trade School
Name of School
City & State
Area of Study
Degree/Certificate/Diploma
*this would include CPhT certifications and licenses
Graduate School
Name of School
City & State
Degree/Certificate/Diploma

Work History
Please include your past 5 years of Professional Work Experience
May we contact your present employer?

YesNo
Have you ever been discharged or asked to resign from a job?

YesNo
If yes, please explain
Please list any special skills you may have that relate to the position(s) you applied for

References
Reference 1
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship (i.e. Family Member, Supervisor, etc.)
example@example.com
Relationship (i.e. Family Member, Supervisor, etc.)
Reference 2
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship (i.e. Family Member, Supervisor, etc.)
example@example.com
Relationship (i.e. Family Member, Supervisor, etc.)
Reference 3
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship (i.e. Family Member, Supervisor, etc.)
example@example.com
Relationship (i.e. Family Member, Supervisor, etc.)

Declaration
I, the applicant, undersigned & agree with the following statements:

I authorize the investigation of all statements contained in the application and release from all liability any persons or employers supplying such information and I also release the company from all liability that might result from making the investigationI certify that the facts and information set forth in this application are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation, or omission of facts on this application will be cause for denial of employment, regardless of when or how discoveredI agree if I am offered and accept a position, to confirm to all existing and future company rules and regulations and I understand that the company reserves the right to change policies, job titles, job description, wages, hours and working conditions as deemed necessary.I understand that, if hired, my employment will be at-will, meaning either party can end the employment relationship at any time and for any reason and that only a written agreement between the president of the company and me, signed by the both of us, can alter the at-will employment relationship.I understand that any employment offer is contingent upon my providing, within three (3) working days of employment, valid proof of identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: