Employment Application - Preferred Pharmacy Solutions

Preferred Pharmacy Solutions - Haverhill, Massachusetts ( MA )

Employment Application For Preferred Pharmacy Solutions

PREFERRED PHARMACY SOLUTIONS
APPLICATION FOR EMPLOYMENT

We are an equal opportunity employer. Federal and state laws prohibit discrimination in employment practices based on race, color, religion, sex, age, handicap, disability, or national origin. No question on this application is asked for the purpose of limiting or excluding any applicant's consideration for employment because of his or her race, color, religion, sex, age, handicap, disability, or national origin.

E-MAIL ADDRESS

E-Mail Address:

POSITION

Facility:
Position Desired:
If Other, indicate position you are applying:
Hours Desired:
Salary Expected:
Note: If you do not remember the Job Code for the job your are applying, please use your browser back button to retrieve it

Last Name

Middle Name

First Name

Social Security No.

Telephone No.

Address

Street

City

State

Zip Code

If your records may be under a name other
than indicated above, please specify:

Licensed Pharmacists Only

Mass. Reg. No

Last Renewal

Date Granted

Expiration Date

Are you a citizen of the United States?

If you are not a U.S. Citizen, do you have the
legal right to remain permanently in the United States?

Explain:

Are you between the age of
18 and 70?

Do you know of any fact that would limit or impair your
ability to perform the functions of the job you are applying for?

Explain:

Date of last Physical
Examination

Family
Physician

I authorize my doctor to release to you the results
of my pre-employment and subsequent medical examinations,
and to discuss those results with you.

Specialized training or experience not shown below:

Where now employed?

Reason for desiring change:

Have you ever pleaded guilty or been convicted of a felony?

If yes to either, please explain:

Or a misdemeanor other than a first conviction for drunkenness, simple assault, speeding, minor traffic violation, affray, or disturbance of the peace within the past 5 years?

IN CASE OF EMERGENCY NOTIFY

Name:
Relationship:
Address:
Telephone:

EDUCATION

Name and Location of School or College		Major Subject
Graduated?	Degree	Attended From	Attended To



Name and Location of School or College		Major Subject
Graduated?	Degree	Attended From	Attended To



Name and Location of School or College		Major Subject
Graduated?	Degree	Attended From	Attended To

FORMER EMPLOYERS AND EXPERIENCE (References)

Name and Address		Nature or Experience
From	To	Salary	Reason for Leaving



Name and Address		Nature or Experience
From	To	Salary	Reason for Leaving



Name and Address		Nature or Experience
From	To	Salary	Reason for Leaving

PERSONAL REFERENCES (Not Relatives)

Name:
Address:
Phone:
Title:
Business:



Name:
Address:
Phone:
Title:
Business:

COVER LETTER
You may "cut and paste" your cover letter in the box below.

RESUME
You may "cut and paste" your resume in the box below.

ANY ADDITIONAL INFORMATION?.

SUBMIT YOUR APPLICATION:

* I authorize the schools, employers, and individuals listed in this application to release any information regarding my previous employment, character, general reputation and personal characteristics:

"It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability."

I certify that the statements I have made in this application are true and hereby grant the employer permission to verify that accuracy and completeness of this information and to investigate all references and educational records. I understand that any false or misleading statements made by me on this application or in conjunction with my physical examination will be sufficient cause for the rejection of this application or for immediate dismissal if such false or misleading information is discovered after my employment. If I am accepted for employment, I agree to abide by the rules and regulations of the employer:

Date:

How did you hear about us?
If Newspaper, what publication?
Other:

Please note that all application information will be kept confidential and will not be sold or released.
Please see our Privacy Policy for more information.

In addition, you will receive a copy of your application form via the e-mail address entered above.

Preferred Pharmacy Solutions is an equal opportunity employer.

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Preferred Pharmacy Solutions, 35 Avco Road, Haverhill, MA 01835
Telephone: (978) 374-9100 Fax: (978) 374-9101