Name (First Middle Last)                                                                        Email

Address                                                                        Phone number

Certification, training or skills


Position you are applying for:                                                        Full or part-time?

Date you can start                           Location preference                               Salary desired

Are you employed currently?                        If so, may be contact your current employer? 

Have you ever applied to this company before?

Are you legally eligible for employment in the United States? (if yes, proof is required if hired) 

If you are under 18 years old, can you provide a work permit if required?

Referred by  


Are you able to perform the essential functions of the job for which you are applying (with or without reasonable accommodation)?


Education Background

High School                                                       Location 

Did you graduate?                                            Years attended

College                                                             Location

Did you graduate?                                            Years attended                       

Course of study

Graduate School, Vocational training, Continuing Education (list school, course of study, degree)




Former Employers

List below last four employers, starting with most recent employer first



1.  Employer 

    Contact Name                                          Hourly rate/salary 

    Job Title

    Dates employed                         to   

   Reason for leaving



​2. Employer 

  Contact Name                                           Hourly rate/salary 

  Job Title

  Dates employed                           to  

  Reason for leaving


​3. Employer 

  Contact Name                                           Hourly rate/salary 

  Job Title

  Dates employed                            to  

  Reason for leaving


4. Employer 

  Contact Name                                          Hourly rate/salary 

  Job Title

  Dates employed                           to  

  Reason for leaving



References

List at least three references.  Include reference's name, phone number, number of years known, relationship








Applicant Statement
  I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.  If hired, I agree to the rules and regulations set by The Drug Store and I understand that these rules and/or the employee handbook do not form a contract of employment either expressed or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time at either my or The Drug Store's option.  I also understand and agree that the terms and conditions of my employment may be changed with or without cause and with or without notice at any time by The Drug Store.  I understand that no company representative, other than its president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the forgoing.  I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights to claims I may have regarding the employer, its agents, employees or representatives seeking, gathering and using truthful and non defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.
I understand that this application remains current for only 30 days.  At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill our a new application. 
The Drug Store does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. The Drug Store takes all harassment complaints seriously and investigates each one promptly and thoroughly.  I understand that this employer does not unlawfully discriminate in employment and no question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.



Signed                                                                  Date










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no previous employer
I have read and understand the applicant statement