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Home
About Us
Specialties
Services
Welcome
Payors
Providers
Providers
Physician's Portal
Careers
Enrollment Forms
Contact Us
APPLICATION FOR EMPLOYMENT
AN EQUAL OPPORTUNITY EMPLOYER (M/F/V/D)
Name
*
First Name
Last Name
Have you ever used any other names?
Yes
No
If yes, list names used with appropriate dates
Current Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Previous Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Position Applied For
Salary Required
Email
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
EDUCATION DATA
High School
Did you graduate?
Yes
No
College
Name
City & State
From
MM
DD
YYYY
To
MM
DD
YYYY
Grade Point Average
Did you graduate?
Yes
No
Type of Degree Received
BS, MS, etc
Course of Study Major-Minor
College
Name
City & State
Grade Point Average
Did you Graduate?
Yes
No
Type of Degree Received
BS, MS, etc
Course of Study Major-Minor
Other
Name
City & State
From
MM
DD
YYYY
To
MM
DD
YYYY
Graduate Point Average
Did you Graduate?
Yes
No
Type of Degree Received?
BS, MS, etc
Course of Study Major-Minor
List academic achievements, and professional awards
List professional and scientific organizations in which you are a member
Describe any graduate work in terms of why chosen, academic emphasis of discipline, and the content of thesis or dissertation:
Graduate work directed by:
List all relevant professional licenses and certifications that you hold and the state(s) in which registration is held
PERSONAL DATA
How did you hear about our company
Consultant /Contractor /Temporary Agency College/University
Professional Association
PP Employee (specify below)
Employment Agency (specify below)
Internet (specify below)
Are you lawfully authorized to work in the U.S.?
No
Yes
Do you require sponsorship to remain working in the U.S.?
No
Yes
Pursuant to the Immigration Reform and Control Act of 1986, all applicants who are offered employment must produce documents establishing their identity and authorization for employment in the United States. These documents must be produced no later than three (3) business days after employment commences. In addition, all new hires will be required to verify their employment authorization under oath by signing INS Form I-9 upon commencing employment.
Have you ever interviewed at Parkway Pharmacy before?
No
Yes
If yes, when?
Have you ever worked at Parkway Pharmacy before?
No
Yes
If yes, when?
Do you have any relatives within Parkway Pharmacy?
No
Yes
If yes, who?
U.S. MILITARY HISTORY
Date Entered
MM
DD
YYYY
Length of Service
Employment Data
List in order, with present or most recent employer first. Please account for all work history including military service and any verified work performed on a volunteer basis. If more space is needed, please use the text box below
1. Employer Name
Employer Address
Employed from
MM
DD
YYYY
to
MM
DD
YYYY
Starting Job Title
Ending Job Title
Phone
(###)
###
####
May we contact?
No
Yes
Supervisor's Name
Supervisor's Title
Present Phone Number
(###)
###
####
Describe your Job Responsibilities:
Reason for Leaving:
2. Employer Name
Employer Address
Employed From
MM
DD
YYYY
to
MM
DD
YYYY
Starting Job Title
Ending Job Title
Phone #
(###)
###
####
May we contact?
No
Yes
Supervisor's Name
Supervisor's Title
Present Phone Number
(###)
###
####
Describe your Job Responsibilities:
Reason for Leaving:
3. Employer Name
Employer Address
Employed From
MM
DD
YYYY
to
MM
DD
YYYY
Starting Job Title
Ending Job Title
Phone
(###)
###
####
May we contact?
No
Yes
Supervisor's Name
Supervisor's Title
Present Phone Number
(###)
###
####
Describe your Job Responsibilities:
Reason for Leaving:
REFERENCES
1. Name
Relationship
Phone
(###)
###
####
Email Contact
2. Name
Relationship
Phone
(###)
###
####
Email Contact
3. Name
Relationship
Phone
(###)
###
####
Email Contact
APPLICANT’S CERTIFICATION
Read these statements carefully before signing; your signature will indicate that you understand the statements and agree to be bound by their terms:
Smoke-free Workplace
*
Smoking is prohibited inside all company buildings operated or occupied Parkway Pharmacy.
I understand
Age Certification
*
I certify that I am at least 18 years of age.
I understand
Truthfulness of information furnished
I certify that the information which I have furnished on this application is true and complete, and I understand that any misrepresentation will be sufficient cause for my not being employed or for dismissal if employed. I also understand that employment is subject to verification of academic and past employment records
I understand
Employment at the will of Parkway Pharmacy
If employed, policies, practices, procedures, benefits, services, and other materials given me are not intended to create or imply a contractual relationship between me and Parkway Pharmacy except as required by law, Parkway Pharmacy reserves the right to amend or discontinue any policies, practices, procedures, benefits, and services at any time. I further acknowledge that Parkway Pharmacy reserves the right to dismiss any employee at any time at their discretion and no written or oral promise of assured employment is effective unless it is expressly set forth in a document signed by an officer of Parkway Pharmacy.
I understand
Signature of Applicant
Date
Thank you!
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