Employment Application Position applying for:Pharmacist in chargePharmacy technicianPharmacy clerkPharmacistInsurance coverage specialistPeer advocateMarketing representativeDriver APPLICANT DATA StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Date available to start: If you are under 18 years of age, can you provide a work permit?: If you are under 18 years of age, can you provide a work permit?YesNo - Please explain Enter other… Have you ever worked at this company?: Have you ever worked at this company?NoYes - When? Enter when… Are you legally allowed to work in the United States?YesNo Type of employment desiredFull-timePart-timeTemporarySeasonal Have you ever pleaded guilty, no contest or been convicted of a crime?: Have you ever pleaded guilty, no contest or been convicted of a crime?NoYes - Give dates and details Enter other… EDUCATION HISTORY Did you graduate High School?yesno Did you graduate?yesno MY PREVIOUS EMPLOYMENTS PREVIOUS EMPLOYMENTBegin with most recent position. You can add up to 3 previous employment references Add Employment Reference Employment 1 From: To: StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming My we contact this employer for a reference?yesno Add one more Employment 2 From: To: StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming My we contact this employer for a reference?yesno Add one more Employment 3 From: To: StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming My we contact this employer for a reference?yesno "I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that, if employed, falsified statements on this application may be grounds for dismissal. I authorize investigation of all statements contained herein. I authorize the references listed and the employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release Perris Hills Pharmacy from all liability for any damage that may result from the utilization of such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws." SIGNATURE Signature of applicant (Please write your name): Signature date: Submit Submit Leave this field blank