Employment

To the best of my knowledge the above requirements do not pose a problem with my continuing to pursue employment with the Integrity Pharmacy.*

I agree

Your Information

Name*

First Middle Last

If you have been known and worked by another name, please indicate:

Email

Address*

Street Address City State ZIP Code

County of Residence

Home Phone

Cell Phone

About the Position(s)

Positions(s) Applying for:*

What position?

Number of hours per week desired*

Hours that you are able to work*

Days that you are able to work*

Date available to begin working*

Tell Us More

How did you learn about our company?*

Integrity Employee
Newspaper
Internet
Other

Name of employee

Where?

Have you ever applied or been employed by Integrity Pharmacy previously?*

No
Yes

When?

Are you a U.S. citizen or legal alien authorized to work in the U.S?*

No
Yes

Please explain

Have you ever plead guilty, been convicted of a crime, received a suspended imposition of sentence (“SIS”) or suspended execution of sentence (SES)?*

No
Yes

Please explain the disposition of the case

Upon reviewing the position job requirements, are there any reasons why you would not be able to perform the essential functions?*

No
Yes

Please describe

Professional Licenses

Please complete the information for each professional license that you hold

Type of License	State of License	Certificate/License	Expiration Date

Click the plus sign + to the right of the row to add more rows.

Education

Highest Grade Completed*

List any schools, colleges or universities you have attended

Name of Institution	Degree, Diploma or Certificate	No of years	Did you graduate? (yes or no)

Employment History

Please list your last three employers below, starting with your most recent or current employer. Please do not leave any blanks incomplete.

#1 Employer Name*

#1 Employer Address*

Street Address City State ZIP Code

Job Title*

Description of Duties*

Supervisor Name*

May we contact?*

Phone

Employed dates*

Employed from	Employed to

Ending Salary*

Salary per*

Reason for leaving*

#2 Employer Name*

#2 Employer Address*

Street Address City State ZIP Code

Job Title*

Description of Duties*

Supervisor Name*

May we contact?*

Phone

Employed dates*

Employed from	Employed to

Ending Salary*

Salary per*

Reason for leaving*

#3 Employer Name*

#3 Employer Address*

Street Address City State ZIP Code

Job Title*

Description of Duties*

Supervisor Name*

May we contact?*

Phone

Employed dates*

Employed from	Employed to

Ending Salary*

Salary per*

Reason for leaving*

Other Experiences

Please List any other experience related to job applying for (paid or unpaid)

Personal References - Not Family Related

Name - Reference #1*

First Last

Address*

Street Address City State ZIP Code

Relationship*

Friend, Minister, etc

Years known*

Phone

Name - Reference #2*

First Last

Address*

Street Address City State ZIP Code

Relationship*

Friend, Minister, etc

Phone

Terms

Applicant Acknowledgement*

I have read and understand the applicant introduction note on the front side of the application form. I verify that the information which I provided in this Application for Employment is true, and that any false information, omissions or misrepresentations of facts requested in this application may result in rejection of my application or immediate termination at any time during my employment with the Integrity Pharmacy.

I authorize Integrity Pharmacy and/or its agents, including consumer reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I also authorize any reference source to provide Integrity Pharmacy with any and all information covering my background and hereby release any said sources from any liability for any damage whatsoever for issuing this information. I also authorize Integrity Pharmacy to register me with the Family Care Safety Registry.

I further agree that Integrity Pharmacy may furnish like information to those with whom I may hereafter seek employment and hereby agree to hold Integrity Pharmacy free and harmless from any and all liability thereafter. I agree to conform to all rules and regulations of Integrity Pharmacy and acknowledge that if my application is accepted and employment engaged, I am an employee at will and have no contractual right of employment.

Integrity Pharmacy is an equal opportunity employer. This application for employment will be current for a period of one year. A new application must be completed if the applicant wishes to be considered for employment after that time.

I agree and understand

Email

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