APPLICATION FOR EMPLOYMENT

PharmaCare Services IS AN EQUAL OPPORTUNITY EMPLOYER. All practices of recruiting, hiring, promotion, transfer, wage and salary administration, benefits and terminations are administered without regard to race, color, creed, sex, religion, national origin, disability, age, veteran status or any and all other unlawful bases regarding federal, state or local laws.

Further, PharmaCare Services is committed to providing a work environment that prohibits, in any form, unlawful harassment. To be considered for employment, all applicants must fill out this form completely. This application will be given every consideration, but its receipt does not imply that the applicant will be employed by the company. This form becomes a part of your permanent employment record if you are hired. This application will be held on file for 30 days. After that time period, applicants are responsible for reapplying.
Click Here for FCRA SUMMARY of Rights

Terms & Conditions (Please go through carefully before submitting the form)
I Agree with Terms and Conditions

PERSONAL INFORMATION
First Name : Address :
Last Name : Zip Code :
Middle Name : City/State :
Area Code - Phone No : Email :
Alternate Phone No. :


TYPE OF WORK DESIRED
Position(s) applying for : Salary $ : Per :
The following conditions might be required at some point in a job assignment. Do you agree to satisfy the following work schedule?
a Shift work? Yes No  
b Overtime work? Yes  No  
c Rotation work? Yes No  
d Work schedule other than Monday to Friday? Yes No  
e Do you agree to work the hours required for your position? Yes No  
f Shift desired? Day Night Evening
Status of employment for which you are applying: Full Time Part Time Per Diem (PRN)

GENERAL INFORMATION
Are you are at least 18 years of age or older? Yes No
Do you have legal right to work in the United States?
 Yes No
Has PharmaCare or any of its subsidiaries ever employed you? If yes, please indicate which subsidiary and dates of employment:
Do you have any relatives employed by PharmaCare or any of its subsidiaries? If yes, please indicate which subsidiary and relative’s name(s):
Yes No
Are you a United States Veteran? If yes, please list dates of separation:
 Yes No
To assist us in our recruitment efforts, please indicate how you were referred to PharmaCare Services :
Walk-in Newspaper AD Job Fair Mailer PCS Website
Employee Referral -Name : Other Website :

SECURITY DATA

Pursuant to the OIG Compliance Program, Employees convicted of criminal offenses or offenses including fraud and abuse related to health care are prohibited from participating in any portion of the direct or indirect health care delivery process. In the event of any pending charges, current employees may be removed from direct responsibility or involvement with any Federal health care program.
Have you ever been convicted or pleaded guilty or no contest to any criminal offense other than a minor traffic violation? (Criminal convictions are not an automatic ban from employment and will only be considered in relation to specific job requirements.)
 Yes No
Have you ever been convicted of a criminal offense related to health care or listed by a federal agency as debarred, excluded or otherwise ineligible for participation in
federal health care programs?
 Yes No
If you answered “yes” to either or the above questions, please briefly describe the circumstances of your conviction indicating the date, nature and place of the offense and disposition of the case.


EDUCATION AND TRAINING
Institution Name and Location		 No. of Years
Completed
Graduated
Yes No
Type of Degree, Diploma
or Certificate and Major
Course of Study		 Academic
Standing
High School
College/
University
Graduate
School
Trade School/
OtherTraining

ACADEMIC ACHIEVEMENTS AND ACTIVITIES:

Please list academic honors, scholarships, or fellowships; memberships in academic honorary societies; or participation in or offices held in extracurricular activities you consider significant. (You may exclude all information of race, color, creed, sex, religion, national origin, disability, age, and veteran status.)

Employment History
Name of Employer : Address :
Area Code & Telephone No :
City/State :
Zip :
Job Title : Salary :
Name of Supervisor : Starting $ :
Dates of Employment: From : To: Per :
Duties Performed :   Ending $ :
Does this Employer issue your paycheck? Yes No  
Is this Employer still in Business? Yes No  
Is this Employer Known Under a different Name(s)? Yes No Names :
Type of Employment? Paid Unpaid Self-Employed  
Reason for Leaving :   Per :
May we contact this employer? Yes No  
Name of Employer : Address :
Area Code & Telephone No :
City/State :
Zip :
Job Title : Salary :
Name of Supervisor : Starting $ :
Dates of Employment: From : To: Per :
Duties Performed :   Ending $ :
Does this Employer issue your paycheck? Yes No  
Is this Employer still in Business? Yes No  
Is this Employer Known Under a different Name(s)? Yes No Names :
Type of Employment? Paid Unpaid Self-Employed  
Reason for Leaving :   Per :
May we contact this employer? Yes No  
Name of Employer : Address :
Area Code & Telephone No :
City/State :
Zip :
Job Title : Salary :
Name of Supervisor : Starting $ :
Dates of Employment: From : To: Per :
Duties Performed :   Ending $ :
Does this Employer issue your paycheck? Yes No  
Is this Employer still in Business? Yes No  
Is this Employer Known Under a different Name(s)? Yes No Names :
Type of Employment? Paid Unpaid Self-Employed  
Reason for Leaving :   Per :
May we contact this employer? Yes No  

LICENSED/CERTIFIED APPLICANTS ONLY
  License No. & State Issued by Expires (Date)
& Status		   License No. & State Issued by Expires (Date)
& Status
Pharmacist ACLS    
Pharmacy Technician          
Please list any other professional memberships, organizations or certifications you hold.

Please indicate any other information you think would be helpful to us in considering you for employment, such as additional work experience, activities, accomplishments, voluntary work experience, and any other languages spoken.

REFERENCES
List at least three references other than relatives or friends.
  Name Address & Phone No. Occupation Years Known
1
2
3
4


READ CAREFULLY BEFORE SIGNING THE APPLICATION FOR EMPLOYMENT:
List at least three references other than relatives or friends.
1

I certify that the answers given by me to the foregoing questions and statements on the employment application and or during the employment interview process are true and correct without any material omissions of any kind whatsoever. I understand that any misleading or incorrect statements may render this application void and, if employed, would be cause for my termination. I further agree that PharmaCare Services shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this application.
2

I authorize the companies schools, persons or entities given during the employment process or on this employment application as references or past employers or affiliations to give any information regarding my employment, character, qualifications, certifications and licenses and hereby release said companies, schools, persons or entities from all liability for any damage for issuing this information.
3

I understand that I may be required to have a medical examination and/or drug and alcohol test after an offer of employment. A favorable result on the medical examination and/or drug and alcohol test shall be a condition of my employment or commencement of any employment duties.
4

I understand that my employment is not for a specified or definite term and that I may resign, or I may be discharged, at any time with or without prior notice. I further understand that this policy cannot be changed or amended except by written agreement signed by me and by a corporate officer.
5

My employment shall be in accordance with the terms of this application, all safety and incident reporting rules, all health care industry compliance program requirements, including adherence to the established Code of Conduct, and all other PharmaCare Services rules, regulations, policies and procedures currently or
hereafter in effect.
6

I certify that as a part of the application process, I have been provided with a written job description or have had the opportunity to review and/or discuss the requirements for the available position. I understand each requirement and certify that I am capable of meeting each and every requirement. I also understand if the
position for which I am applying requires licenses and/or certifications, it is my responsibility and a requirement for continued employment to maintain valid licenses and/or certifications.