REQUIREMENT FOR ALL EMPLOYEES
In compliance with Missouri law, employees are required to be registered with the Missouri State Board of Pharmacy. This process includes a background check and finger printing. In the event you are unable to be registered or your registration is declined by the Board, Family Pharmacy reserves the right to refuse or terminate your employment.
REQUIREMENT FOR ALL DELIVERY DRIVERS
In compliance with Missouri law, employees who "deliver goods" (such as pharmaceuticals) for a company must obtain and maintain a Class E driver's license. To obtain a Class E license in the state of Missouri, you must be at least 18 years old.
Position Applied For:
Date of Application:
Name:
Last
First
Middle
 
Address:
Street
City
State
Zip
Home Phone#: Cell Phone#: Email Address:
Date Available to Start:
Type of employment desired: Full-Time Part-Time Temporary
If Part-Time, what hours/days are you available?
Have you ever been terminated from or asked to leave a job? Yes No If yes, please explain:
Have you worked here before? Yes No
Only those who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, submit documentation of your identity and your legal right to work in the U.S.? Yes No
If you are 17 years old or younger, please enter your age:
Are you willing to work overtime if asked? Yes No
Work Experience
FROM
TO
EMPLOYER
PHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
NATURE OF THE WORK AND RESPONSIBLITIES
REASON FOR LEAVING
HOURLY RATE /SALARY
FROM
TO
EMPLOYER
PHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
NATURE OF THE WORK AND RESPONSIBLITIES
REASON FOR LEAVING
HOURLY RATE /SALARY
FROM
TO
EMPLOYER
PHONE
JOB TITLE
ADDRESS
IMMEDIATE SUPERVISOR AND TITLE
NATURE OF THE WORK AND RESPONSIBLITIES
REASON FOR LEAVING
HOURLY RATE /SALARY
We will contact your employers listed above unless you specify otherwise.
Do not contact: Reason:
Do not contact: Reason:
Education
School Name and Location of School Course of Study # of Years
Completed
Did you
graduate?
Degree or
Diploma
Graduate
College
Business/
Trade/
Technical
High School
Elementary
Membership in Professional or Civic Organizations
Special Requirement for Employment:
All employees are required to be registered with the State Board of Pharmacy. In the event that you are unable to be registered or your registration is declined by the board, Family Pharmacy reserves the right to refuse or terminate your employment.
Special Training or Skills
APPLICANTS CERTIFICATION AND AGREEMENT: Please read and acknowledge the following statement with your signature

I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Family Pharmacy to verify their accuracy and to obtain reference information on my work performance. I release Family Pharmacy from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for termination.

I understand that should an employment offer be extended to me, and accepted, I will fully adhere to the policies, rules and regulations of employment at Family Pharmacy. I further understand that neither the application, policies, rules, regulations of employment nor anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at-will and that either I or Family Pharmacy may terminate my employment at any time with or without notice. My electronic signature below verifies that I have read and understand the foregoing statements.

Electronic Signature:
Date:

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