IPD Employment Application Form V3

PERSONAL INFORMATION:
Name*

First NameMiddle Name (Enter N/A if no middle name)Last Name
Birth Date*

MonthDayYear
Date
Phone Number*
Permanent Residence Street Address (do not enter a PO box)*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Street Address is the same as Permanent Address

YesNo
Mailing Street Address (PO box allowed)*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Social Security Number (No dashes)*
Driver's License Number*
State Issued*

Street Address

Street Address Line 2

CityState

Zip Code
Upon employment, can you show verification of your legal right to work in the United States?*

YesNo
Are you at least 18 years old?*

YesNo
To continue in the hiring process IPD must recieve a Youth Employment Certificate. Please click the link and complete the Youth Employment Certificate

EDUCATION:
Highest Grade Completed*
High School:*
High School City/State:*

Street Address

Street Address Line 2

CityState

Zip Code
Highest Grade Completed:*
Technical or Trade School*
Technical or Trade School City/State*

Street Address

Street Address Line 2

CityState

Zip Code
Major Course of Study*
Did you graduate?*

YesNo
College*
College City/State*

Street Address

Street Address Line 2

CityState

Zip Code
List Degree/Certificate*
Major Course of Study:*
Did you graduate?*

YesNo
Post-Graduate School:*
Post-Graduate School City/State*

Street Address

Street Address Line 2

CityState

Zip Code
Major Course of Study*
Post-Graduate Degree*
Activities, Honors, Offices held that are job related
Please DO NOT INCLUDE those which indicate race, religion, national origin, color, sex, age or disability
Describe other job-related training completed
Please DO NOT INCLUDE those which indicate race, religion, national origin, color, sex, age or disability

References

Please list three (3) references that are familiar with your work life.
Reference*
Reference*
Reference*
PLEASE READ AND SIGN
I hereby authorize the company, Independent Pharmacy Distributor, LLC to fully investigate my record and work qualifications either before or during my employment, and to facilitate investigation, I also hereby authorize any persons having knowledge thereof to give such information to the company, upon request.

Icertify that all statements made by me on this application are true and correct to the best of my knowledge and belief, and agree that any misrepresentation, falsification or omission of facts thereon shall be sufficient cause to deny my employment or if employed to justify my dismissal. The company is an equal opportunity employer and does not because of race, creed, color, sex, marital status, age, national origin, handicap, veteran status, or sexual preference. I understand that the company conducts a full background investigation on all employees, including but not limited to National Sex Offender List, Office of the Inspector General, Criminal background, and credit history. I understand that any offer of employment is conditional on my ability to establish eligibility under the Immigration Reform and Control act of 1986.
Printed Name*

First NameMiddle NameLast Name
Signature*

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Date

MonthDayYear
Date

DRUG TESTING CONSENT

Please provide the following to apply for employement:
As a condition for my application being considered, I understand and agree to undergo substance screening if requested. I understand that if tested and results are positive, I shall not be considered further by the company.

I hereby authorize any physician, laboratory, hospital or medical professional retained by the company to conduct such screening and to provide the results to the company, and release the company and any person affiliated with the company and any such institution or person conducting the screening from any liability.
PERSONAL INFORMATION:
Name*

First NameMiddle Name (Enter N/A if no middle name)Last Name
Birth Date *

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Permanent Residence Street Address (do not enter a PO Box)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drivers License Number*
State Issued*

Street Address

Street Address Line 2

CityState

Zip Code
PLEASE READ AND SIGN BELOW
All statements and information given in this application are true to the best of my knowledge and belief. Failure to provide truthful responses may prejudice my rights to Worker's Compensation benefits pursuant to State Statues.
Printed Name*

First NameMiddle NameLast Name
Signature*

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Date*

MonthDayYear
Date

Click the check box confirming that you understand the following:

I understand that this is not a work from home jobI understand that IPD Sales Rep position hours are from 10am-7pm
I would say that I use Microsoft Office (Word, Excel and Outlook)
How do you feel about public speaking
Should be Empty:

Employment Application