App for Pharmacists & Technicians


 

On The Hill Health Mart Pharmacy

Employment Application

Applications are considered without regard to race, color, religion, sex, national origin, age, marital or veteran status, or the presence of a non-job-related medical condition or handicap

5378 Southwest Ave

St. Louis, MO 63139

(p)314-776-9460

(f)314-776-9463

 

 

Applicant Information

Last Name

 

First

 

M.I.

Date

 

Street Address

 

Apartment/Unit #

 

City

 

State

 

ZIP

 

Phone

 

E-mail Address

 

Date Available

 

Social Security No.

 

Desired Salary

 

Position Applied for

 

Are you a citizen of the United States?

YES 

NO 

If no, are you authorized to work in the U.S.?

YES 

NO 

Have you ever worked for this company?

YES  

NO  

If so, when?

 

Have you ever been convicted of a felony?

YES  

NO  

If yes, explain

 

If applying for Technician position, are you certified?                         If yes, CPhT License #:

Education

High School

 

Address

 

From

 

To

 

Did you graduate?

YES 

NO 

Degree

 

College

 

Address

 

From

 

To

 

Did you graduate?

YES 

NO 

Degree

 

Other

 

Address

 

From

 

To

 

Did you graduate?

YES 

NO 

Degree

 

 

References

Please list three professional references.

Full Name

 

Relationship

 

Company

 

Phone

 

Address

 

Full Name

 

Relationship

 

Company

 

Phone

 

Address

 

Full Name

 

Relationship

 

Company

 

Phone

 

Address

 

                                                     

 

 

 

Previous Employment

Company

 

Phone

 

Address

 

Supervisor

 

Job Title

 

Starting Salary

$

Ending Salary

$

Responsibilities

 

From

 

To

 

Reason for Leaving

 

May we contact your previous supervisor for a reference?

YES 

NO 

 

Company

 

Phone

 

Address

 

Supervisor

 

Job Title

 

Starting Salary

$

Ending Salary

$

Responsibilities

 

From

 

To

 

Reason for Leaving

 

May we contact your previous supervisor for a reference?

YES 

NO 

 

Company

 

Phone

 

Address

 

Supervisor

 

Job Title

 

Starting Salary

$

Ending Salary

$

Responsibilities

 

From

 

To

 

Reason for Leaving

 

May we contact your previous supervisor for a reference?

YES 

NO 

 

 

Military Service

Branch

 

From

 

To

 

Rank at Discharge

 

Type of Discharge

 

If other than honorable, explain

 

 

Disclaimer and Signature

I CERTIFY that the above answers are true and complete to the best of my knowledge.  I authorize Health Mart Pharmacy or its agent(s), to investigate any statement contained in this application and to obtain a consumer credit report on me (and my company if this application is for reselling by a company) as necessary to determine my qualifications.  I understand that this application is not and is not intended to be any kind of contract or agreement.  In the event of employment, I understand that any false or misleading information given in my application, correspondence, discussions or interview may result in immediate termination.  I understand also, that I am required to abide by all rules, regulations and policies of Health Mary Pharmacy.

Signature

 

Date

 

Applications may be faxed to the above fax number or brought in person.