Hi-School Pharmacy EMPLOYMENT APPLICATION FORM
Blank Application

Desired Store Location:

Fields with * are Required

EQUAL OPPORTUNITY STATEMENT
  Hi-School Pharmacy/Hardware and Affiliates is an equal opportunity employer, dedicated to a policy of nondiscrimination in employment on the basis of race, color, sex, sexual orientation, gender identity, marital status, religion, creed, age, national origin, citizenship status, workers’ compensation status, physical or mental disability, genetic information, veteran status or any other status protected under applicable local, state or federal nondiscrimination law. It is our intention that all applicants be given equal opportunity and that selection decisions are based on job-related factors. Any person needing reasonable accommodation in the application process should notify the hiring manager. Please enter your responses and fill this form out completely in order to have your application considered.  
PERSONAL INFORMATION
 Last Name  *  M.I.   First Name  *
 Address  *  City  *  State  *  Zip  *
 Home Phone   Mobile Phone   Email Address 
GENERAL INFORMATION

How were you referred to us? *

 Ad School  Self Agency
 Employee  Other

Have you ever worked for this Company? *  Yes No

If Yes, provide location, date left, and reason for leaving:
 

There are several Hi-School Pharmacy locations. Are you willing to work at other locations? *

Yes No

 

Date Available to Begin Work:
*

Available *

Full-Time
Part-Time
Temporary/Seasonal

Shift Available *

Days
Swing
Weekend

List other names under which you worked or attended school.
(Include maiden name.)

Names of any relatives working for Hi-School Pharmacy or its affiliates:

 

Position Desired:
*

Salary Expected: $ per 

Are you 16 years of age or older? *

Yes No

Are you willing to work shifts including weekends, and holidays if required? *

Yes No

List any hours you are not willing to work:

Do you have a reliable way to get to work? *

Yes No

Can you, upon employment, submit verification of your legal right to work in the United States and provide documentation verifying your identity?  * Yes No
Can you perform all essential functions of the job(s) for which you have applied, either with or without reasonable accommodation? * Yes No

EMPLOYMENT HISTORY
(Information may be verified. Telephone numbers are very important.)

Please list all work experience, paid or unpaid, beginning with your current or most recent employer and including volunteer work, self-employment and U.S. Military service. This section must be fully completed.

 Month/Year  Company Name
 
 Position
 
 Beginning Salary
 
 Ending Salary
 
 Address
 
 Supervisor
 
Job Duties
 From
 
 City
 
 State
 
 Zip
 
 To
 
 Phone
 
 Reason for Leaving
 
 May we contact this employer at this time? Yes No
 
 Month/Year  Company Name
 
 Position
 
 Beginning Salary
 
 Ending Salary
 
 Address
 
 Supervisor
 
Job Duties
 From
 
 City
 
 State
 
 Zip
 
 To
 
 Phone
 
 Reason for Leaving
 
 May we contact this employer at this time? Yes No
 
 Month/Year  Company Name
 
 Position
 
 Beginning Salary
 
 Ending Salary
 
 Address
 
 Supervisor
 
Job Duties
 From
 
 City
 
 State
 
 Zip
 
 To
 
 Phone
 
 Reason for Leaving
 
 May we contact this employer at this time? Yes No
 
 Month/Year  Company Name
  
 Position
 
 Beginning Salary
 
 Ending Salary
 
 Address
  
 Supervisor
 
Job Duties
 From
 
 City
 
 State
 
 Zip
 
 To
 
 Phone
 
 Reason for Leaving
 
 May we contact this employer at this time? Yes No
EDUCATION
   Name & Location of School  Diploma or Degree  Major
 High School    Graduated? Yes No  
 College    Degree   
 Other    Degree   

 Trade, Business, Correspondence School

   Degree   
ADDITIONAL INFORMATION/SPECIAL SKILLS

Use this space to provide any relevant information about yourself or your background that you feel should be taken into account in considering your application. List specific skills, abilities, training, scholastic honors or scholarships, offices held, certifications, academic activities, or special accomplishments.

References

Give below the names of three professional references (other than previous employers or relatives) that we may contact.
Providing this information means that you give Hi-School Pharmacy permission to contact the references listed.

 Name   E-Mail Address 
 Phone   Business and Occupation 
 
 Name   E-Mail Address 
 Phone   Business and Occupation 
 
 Name   E-Mail Address 
 Phone   Business and Occupation 
APPLICANT'S CERTIFICATION - Please read carefully and check each statement before signing

* I understand that the Company reserves the right to condition my employment upon a satisfactory drug test and background check. I further understand that if I am employed, the Company reserves the right to subject me to drug and alcohol testing if it has reason to believe that I am using drugs or under the influence of alcohol.

* I authorize investigation of all information provided during the application process and the references listed above to give the Company any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release from all liability or responsibility this Company, its agents and all persons, companies or corporations providing information to the Company about me.

*  If hired, I agree to conform to the rules and policies of the Company including the anti-discrimination and harassment policy set forth in the Employee Handbook. I understand that, if hired, my employment and compensation can be terminated at any time and for any lawful reason, with or without notice, at the option of either the Company or myself. I further understand that although other terms and conditions of employment may change, this at-will employment relationship will remain in effect throughout my employment with the Company unless specifically altered by the Senior Vice-President of Operations in a writing signed by the Senior Vice-President of Operations. This at-will employment relationship may not be modified by any oral or implied agreement or by a person, statement, act, or pattern of conduct. I understand that no representative of the Company, other than the Senior Vice- President of Operations, has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

*  I certify that I have answered truthfully and have not knowingly withheld any information relative to my application. I understand that any misrepresentation or material omission on this application will result in disqualification for employment. I further understand that, if accepted for employment, any misrepresentation that becomes known to the Company may result in immediate termination.


Attach Resume (.doc or .pdf):


Applicant's Signature  *           Date  *