Last Name
*
First Name
*
MI
Date
*
/
Month
/
Day
Year
Date
Street Address
*
Apartment/Unit
City
*
State
*
ZIP Code
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date Available
*
/
Month
/
Day
Year
Date
DaysHours Available
*
Are you a citizen of the United States
*
Please Select
Yes
No
If not a US citizen, are you authorized to work in the US?
Please Select
Yes
No
Do you have a NYS drivers license?
*
Please Select
Yes
No
How long have you had your drivers license?
Have you ever been convicted of a felony?
*
Please Select
Yes
No
If yes explain
Education
High School Attended
*
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Did you graduate high school?
*
Please Select
Yes
No
Degree
College Attended
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Did you graduate?
Please Select
Yes
No
Degree
Other education
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Degree
References
Please list at least two professional references
Reference 1 Full Name
*
Relationship
*
Company
*
Address
*
Reference 2 Full Name
*
Relationship
*
Company
*
Address
*
Reference 3 Full Name
Relationship
Company
Address
Previous Employment
Company
*
Address
*
Supervisor
*
Job Title
*
Responsibilities
*
From
*
-
Month
-
Day
Year
Date
To
*
-
Month
-
Day
Year
Date
Reason for Leaving
*
May we contact your previous supervisor for a reference?
*
Please Select
Yes
No
Company
Address
Supervisor
Job Title
Responsibilities
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May we contact your previous supervisor for a reference
Please Select
Yes
No
Company
Address
Supervisor
Job Title
Responsibilities
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Reason for Leaving
May we contact your previous supervisor for a reference?
Please Select
High School Students
What extracurricular activities are you involved in (sports, play, etc.)?
Do you plan on attending college?
Please Select
Yes
No
Would you like more hours during the summer and other school breaks?
Please Select
Yes
No
What positions are you interested in? (may select more than one)
*
Cashier
Delivery Driver
Pharmacy Technician
Pharmacist
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, / understand that false or misleading information in my application or interview may result in my release.
*
Date
*
/
Month
/
Day
Year
Date
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