MediCenter Employment Form

Employment Application
Thank you for your interest in and application for employment with MediCenter Pharmacy. We are an equal opportunity employer and give employment and promotional consideration without regard to race, color, creed, sex (including pregnancy), religion, marital status, age, national origin or ancestry, physical or mental disability, medical condition, genetic information, gender identity or expression, sexual orientation, military status, or any other consideration made unlawful by federal, state, or local laws.
General Information
What position are you interested in?*
Select a MediCenter Pharmacy location*
Name*

First NameMiddle InitialLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email Address
Are you legally able to work in the United States?*

YesNo
Have you ever been convicted of a crime other than a traffic violation?*

YesNo
Employment Desired:
Position for which application is being made (be specific):*
Are you at least 18 years old?*

YesNo
I am available to work: (check all that apply)*

Full TimePart TimeTemporaryWeekdaysWeekendsMorningsAfternoonsEveningsNights
Date Available:*

MonthDayYear
Date
Expected Compensation*
Education

High School, College, Trade Schools, and Other Education
Highest Level of Education Attained:*
Major Field of Study*
Last Year Completed*

1234
Did you graduate?*

YesNo
School Name*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second Highest Level of Education Attained:
Major Field of Study*
Last Year Completed*

1234
Did you graduate?*

YesNo
School Name*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Third Highest Level of Education Attained:
Major Field of Study*
Last Year Completed*

1234
Did you graduate?*

YesNo
School Name*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Education Attained:
Major Field of Study*
Last Year Completed*

1234
Did you graduate?*

YesNo
School Name*
School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment History

List most recent first, then preceding; include any military service
Employer Name
Job Title
Employment Start

MonthDayYear
Date
Employment End

MonthDayYear
Date
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Starting Compensation
Ending Compensation
Supervisor's Name
Reason for Leaving:
Description of Duties and Responsibilities (include promotions and advancements):
Employer Name
Job Title*
Employment Start*

MonthDayYear
Date
Employment End

MonthDayYear
Date
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Starting Compensation
Ending Compensation
Supervisor's Name*
Reason for Leaving:
Description of Duties and Responsibilities (include promotions and advancements):*
Employer Name
Job Title*
Employment Start*

MonthDayYear
Date
Employment End

MonthDayYear
Date
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Starting Compensation
Ending Compensation
Supervisor's Name*
Reason for Leaving:
Description of Duties and Responsibilities (include promotions and advancements):*
References

List two non-relative employment references whom you have known for at least one year
Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Years Acquainted*
Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Years Acquainted*
Please read the following statements, ask any questions, and sign below.
I certify that the above information is true and correct and give authorization for investigation of all statements and information contained in this application, my resume, other documents or verbally obtained during an employment interview. I voluntarily consent to allow MediCenter Pharmacy or any of their representatives or agents to check my references by contacting any persons, company or governmental entity they deem to be an appropriate reference. I understand the reference questions may pertain to my personal or educational background, work experience, character and behavior. I understand my employment is subject to satisfactory verification of this information and agree that deliberate falsification of this document or significant omissions shall be grounds for employment consideration disqualification or dismissal from employment, if discovered at a later date. I also realize that company policies, procedures, practices or statements made during an interview or employment do not create an employment contract by implication or otherwise. I further understand and agree that my employment is for no definite period of time and may, regardless of time and manner, be terminated by the company or myself with or without cause or previous notice.
Signature of Applicant*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
This application is valid only for 60 days frm the date singed/dated above.
Please verify that you are human*
Should be Empty:

Employment Application

General Information

Employment Desired:

Education

Employment History

References

Please read the following statements, ask any questions, and sign below.