Application and Drug Free Workplace Policy

Name*

Social Security No.*

Present Address*

City*

State*

Zip/Postal Code*

Telephone No. Home*

E mail*

example@example.com

Street*

City

State

Position Applied For*

Date Available For Employment*

Date

Salary Desired*

Would You Accept Another Position?*

YesNo

Overtime (over 40 hrs/wk)*

YesNo

On Call*

YesNo

Rotating Shifts*

YesNo

Nights*

YesNo

Weekends (Sat/Sun)*

YesNo

Holidays*

YesNo

Travel*

YesNo

Experience with Microsoft Excel*

Experience with Microsoft Powerpoint*

Experience with Microsoft Word*

Experience with WordPerfect*

Other Job-Related Skills*

Are you applying for*

Full TimePart TimePermanentTemporary

How were you referred to this organization*

Do you have any relatives working for this organization*

YesNo

If yes, name

Relationship

Department

Have you ever been employed by this organization*

YesNo

If yes, position

Department

From

To

Are you a US citizen*

YesNo

If no, do you have a legal right to work in the United States

YesNo

Are you older than 18 and less than 70?*

YesNo

If no, please specify age

Do you have any physical defects or impediments which might, in any way, hinder your ability to perform the job for which you have applied?*

YesNo

If yes, please explain*

Since reaching age 18, have you ever been convicted of a misdemeanor or felony? (Note: Convictions will not necessarily bar you from employment, but are reviewed as related to the relevancy of the job applied for)*

YesNo

If yes, please explain*

Military Service*

YesNo

If yes, from

To

Branch of Service

Highest Rank

In an emergency, notify*

First NameLast Name

Address*

Telephone No.*

High School Name and Address*

Last Year Completed*

1234

Did you graduate*

YesNo

Diploma/Degree*

College Name and Address

Course of Study

Last Year Completed

1234

Did you graduate

YesNo

Diploma/Degree

College Name and Address

Course of Study

Last Year Completed

1234

Did you graduate

YesNo

Diploma/Degree

Technical, Business, or Professional School Name and Address

Course of Study

Last Year Completed

1234

Did you graduate

YesNo

Diploma/Degree

Please list name, address, and phone number of previous employers with most recent employers first. Periods of unemployment should be included.

Job Title*

From Date*

Date

To Date*

Date

Immediate Supervisor*

Last Salary (Hourly, Monthly, or Yearly)*

Employer*

Employer Address*

Employer Phone Number*

Please enter a valid phone number.

Job Duties*

Reason For Leaving*

Job Title*

From Date*

Date

To Date*

Date

Immediate Supervisor*

Last Salary (Hourly, Monthly, or Yearly)*

Employer*

Employer Address*

Employer Phone Number*

Please enter a valid phone number.

Job Duties*

Reason For Leaving*

Job Title*

From Date*

Date

To Date*

Date

Immediate Supervisor*

Last Salary (Hourly, Monthly, or Yearly)*

Employer*

Employer Address*

Employer Phone Number*

Please enter a valid phone number.

Job Duties*

Reason For Leaving*

May we run an employment check from the employers listed above?*

YesNo

Has notice been given to present employer?*

YesNo

Is there any additional information relative to change in name necessary to check your work history?*

YesNo

If yes, please explain*

Please list three references (not relatives or employers) to contact who are acquainted with your work history.

Name*

Title/Occupation*

Company/Address*

Phone Number*

Please enter a valid phone number.

Name*

Title/Occupation*

Company/Address*

Phone Number*

Please enter a valid phone number.

Name*

Title/Occupation*

Company/Address*

Phone Number*

Please enter a valid phone number.

Make any comments you fell are pertinent to your application*

I authorize you, at the time of my application for employment or during the course of my employment, to obtain information from any source as to my education, experience, competence, character or medical history, as it relates to the position for which I applied or in which I may be employed unless otherwise stated. I ceretify that the information contained in this application is tru, complete, and correct to the best of my knowledge and belief. I understand that any falsification or omission of information may cause my immediate dismissal or rejection of this application. I agree that all statements made in this application may be investigated. I also understand that I may be required to successfully complete a medical exam for initial and continued employment. I further understand that in the event I am employed, such employment is at will. Neither I nor the employer have agreed on any specific period of employment nor any specific pay or benefits otherwise set forth in a separate contract.

Date*

Date

Signature*

RelyCare Pharmacy is committed to providing an employment environment that is safe and provides appropriate motivation to ensure a creative and productive work force. RelyCare Pharmacy endorses the philosophy that the work place should be free from the detrimental effects of illicit drugs. To ensure worker safety and work place integrity, RelyCare Pharmacy prohibits the illegal manufacture, possession, distribution, or use of controlled substances by its employees or those who engage or seek to engage in business with RelyCare Pharmacy.

In an effort to assure employees of a work place free from illegal drugs and their effects, RelyCare Pharmacy will implement the following Drug Free Work Place Policy:

1. Policy: It is unlawful to illegally manufacture, distribute, dispense, possess, or use a controlled

2. Procedures

a. It is the policy of the pharmacy that all employees and each new hire will receive a drug screening when hired and at random intervals during their term of employment with RelyCare Pharmacy.

b. Each employee will review a copy of the Drug Free Work Place Policy stating it is unlawful to illegally manufacture, distribute, dispense, possess, or use a controlled substance. Each employee will sign and date the statement certifying that she/he:

1. Understands and will abide by the Drug Free Work Place Policy;

2. Has knowledge of disciplinary actions which may be imposed for violations of the Drug Free Work Place Policy. The signed and dated statement will be forwarded to the individual in charge of personnel records. The signed and dated statement will be permanently part of the employee's personnel file.

3. Disciplinary Action:

a. If an employee is convicted of violating any criminal drug statue she/he will be subject to

b. If an employee fails a drug screening test, they will be subject to immediate termination.

c. An employee is required to report within five days any criminal drug statue conviction.

Employee Name*

Signed*

Date*

Date

Application and Drug Free Workplace Policy

DRUG FREE WORK PLACE POLICY

I certify that I have read this Drug Free Work Place Policy and agree to comply with it.