Job Application – Pierce Pharmacy Management

Education
Name of High School
Address
City and State
Zip Code
Highest Grade Completed
Graduated?
Yes
No
If not a high school graduate, do you have a GED?
Yes
No
Post High School 1:
City and State
Major
If no degree, specify hours earned (quarter/semester)
Type of Degree
Year Degree Earned
Post High School 2:
City and State
Major
If no degree, specify hours earned (quarter/semester)
Type of Degree
Year Degree Earned
Post High School 3:
City and State
Major
If no degree, specify hours earned (quarter/semester)
Type of Degree
Year Degree Earned
Post High School 4:
City and State
Major
If no degree, specify hours earned (quarter/semester)
Type of Degree
Year Degree Earned
References
Give the name, address and phone number of three references that ARE NOT related to you and ARE NOT previous employers.
Reference 1
First Last

Relationship
Phone
Address
City and State
Reference 2
First Last

Relationship
Phone
Address
City and State
Reference 3
First Last
Relationship
Phone
Address
City and State

Work Experience
Describe your work history beginning with your current or most recent job. Include military and volunteer experience and periods of unemployment. Failure to give complete information regarding each job held may result in your disqualification. Complete addresses with zip codes and telephone numbers for all employers are necessary.
1. Name of Organization or Firm:
Phone
Address
City and State
Zip Code
Dates Employed: From month/year
To month/ year
Total Time Employed
Pay Start
End
Official Job Title
Supervisor
Describe Your Specific Job Duties
Specific Reason for Leaving
2. Name of Organization or Firm:
Phone
Address
City and State
Zip Code
Dates Employed: From month/year
To month/ year
Total Time Employed
Pay Start
End
Official Job Title
Supervisor
Describe Your Specific Job Duties
Specific Reason for Leaving
3. Name of Organization or Firm:
Phone
Address
City and State
Zip Code
Dates Employed: From month/year
To month/ year
Total Time Employed
Pay Start
End
Official Job Title
Supervisor
Describe Your Specific Job Duties
Specific Reason for Leaving
4. Name of Organization or Firm:
Phone
Address
City and State
Zip Code
Dates Employed: From month/year
To month/ year
Total Time Employed
Pay Start
End
Official Job Title
Supervisor
Describe Your Specific Job Duties
Specific Reason for Leaving
Are you currently employed?
Yes
No
May we contact your present employer?
Yes
No
Describe any additional training, skills or extra-curricular activities:
Computer Skills: WPM?
Computer Skills:
Spreadsheet
Word Processing
Additional skills:
List machinery and equipment, certifications or other qualifications that relate to the type of work for which you are applying:
If you have read the job description, are you able to perform all duties listed?
Yes
No
If no, please explain what can be done to provide you with reasonable accommodation?

Authorization to Release Information & Conditions of Employment
I have made application for employment with Pierce Phamacy Management. I authorize any persons or organizations to give the company any and all information concerning my previous employment, education or any other information, personal or otherwise, with regard to any of the subjects covered by this application. I release all parties from liability for any damage whatsoever for issuing same. Furthermore, I acknowledge that if I become employed by the company, my employment will be at-will and may be terminated with or without cause at any time by me or by the employer. If required, for the position which I am applying, I consent to undergo a physical examination and/or psychological examination after I have received a conditional offer of employment, as deemed necessary. Before any applicant can be employed with the company they must successfully pass all required examinations. You must select yes to “Authorization to Release Information & Conditions of Employment”, even though we may not contact your present employer.*
Yes
No
Applicant’s Certification & Agreement
I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge. I am aware that the falsification of this application or the omission of complete information will result in disqualification, or upon discovery, termination of employment. The company is hereby authorized to make any investigation of my prior educational and work history. Finally, I agree that all records submitted (i.e: resumes, letters of reference) or generated for purposes of employment are property of and shall remain the property of the compnay. The information provided on the application is subject to public disclosure under the Georgia Open Records Act.*
Yes
No
Alcohol & Controlled Substance Testing
As a condition of employment with the company, you will be required to submit to an alcohol and controlled substance test. Employees must, as a condition of employment, abide by the company’s policies regarding the effects of drug use and the unlawful possession of controlled substances. Employees are expected to report for work without the effects of illegal drugs and alcohol in their bodily systems. Employees must report any conviction under a criminal drug statute for such violations. In order to be employed by the company, you must successfully pass the aforementioned testing and will be required to undergo random drug testing for the duration of employment. By selecting yes, I acknowledge the above and consent to such an examination and test.*
Yes
No

PPM Job Application

Step 1 of 4 - cvbxxb

Personal Data

DRIVER’S HISTORY INFORMATION

Education

References

Work Experience

Authorization to Release Information & Conditions of Employment

Applicant’s Certification & Agreement

Alcohol & Controlled Substance Testing