Employment Application

4062 Hixson Pike, Chattanooga, TN 37415 · P: 423-877-3568

Present Address

City / State

Código postal

Alternate Phone

Are you at least 18 years old?

Yes

Were you ever employed under a different name?

Yes

If yes, please list the name

Are you legally eligible for employment in the United States?

Yes

If no, please explain

Have you ever had a record of arrest, have criminal charges pending, or have a conviction of a felony, misdemeanor, or traffic violation (even if sealed or expunged, regardless of date of conviction). DO NOT CHECK YES for parking violations, speeding tickets and violations such as failure to obey a red light, failure to use a turn signal or expired registration.

Yes

If yes, please explain

Have you ever been employed by Access Family Pharmacy?

Yes

If yes, position held and department

Dates of employment and reason for leaving

Please list any immediate relatives who work for Access Family Pharmacy

Were you referred to our company or have you ever applied with our company previously?

Yes

If yes, please include who referred you or when you last applied.

Are you able to perform the essential functions of the position with or without reasonable accommodations?

Yes

If no, please include any details.

Have you ever been involuntarily terminated or involuntarily dismissed from a former position or job? NOTE: Conviction of a crime or involuntary termination is not an automatic bar to employment; all circumstances will be considered.

Yes

If yes, please explain.

Type of work or position(s) applying for include:

Date available to work

What hours would you be available to work?

Desired Salary

Please select all that apply

Days

Nights

Weekends

Rotation

Employment Status Desired

Full-Time

Part-Time

On-Call

Education Background

Name/Location of School

Course of Study

Type of Degree

Years Completed

Are you a high school graduate or GED/equivalent?

Yes

Specialized training, apprenticeships and extracurricular activities (Exclude those which may be indicative of sex, age, race, color, religion, military status, disability or national origin)

Software programs in which you are proficient

Equipment you have skills to use

Professional License/Registration/Certification Information

Type of License/State

License Number

Expiration Date

Type of Registration/State

Registration Number

Expiration Date

Type of Certification/State

Certification Number

Expiration Date

Email Address

Primary Phone

Relationship

Years Known

Email Address

Primary Phone

Relationship

Years Known

Email Address

Primary Phone

Relationship

Years Known

Most Recent or Current Employer

Wage

Job Title

Dates Employed

Phone

Supervisor's Name

Supervisor's Email Address

Reason for leaving

Employment Status

Full

Part

On-Call

You may contact this employer:

Yes

Previous Employer

Wage

Job Title

Dates Employed

Phone

Supervisor's Name

Supervisor's Email Address

Reason for leaving

Employment Status

Full

Part

On-Call

You may contact this employer:

Yes

Previous Employer

Wage

Job Title

Dates Employed

Phone

Supervisor's Name

Supervisor's Email Address

Reason for leaving

Employment Status

Full

Part

On-Call

You may contact this employer:

Yes

Name

Phone Number

Relationship

All employment offers are made following successful results of pre-employment testing, drug screening, reference checks and background investigational checks. If I accept employment at Access Family Pharmacy, I understand and agree that any misrepresentation or omission of facts called for in my application, or any other Access Family Pharmacy related document, now or in the future, will render my application void, bar me from any future employment with Access Family Pharmacy, and/or result in my immediate separation from Access Family Pharmacy. I understand that my employment is at-will and may be terminated either by me or by Access Family Pharmacy at any time with or without notice for any reason.

I understand that no employee of Access Family Pharmacy has the authority to alter my at-will employment status, or the policies of Access Family Pharmacy (with which I agree to comply in consideration of my employment if I am employed), except the Director, who may only do so in writing. I understand and agree that any claim or lawsuit relating to my service with Access Family Pharmacy must be filed not more than six (6) months after date of employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

Date

Signature

By entering your name and submitting this application, you are giving Access Family Pharmacy permission to investigate your past work history.
This application will be considered active for one year, after which you must reapply.

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Access Family Pharmacy
4062 Hixson Pike, Chattanooga, TN 37415
(423) 877-3568

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