Application for Employment

Application for Employment
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Is there any information about your name or use of another name that we would need to check your work record? If so, please specify
Position applied for
Do you have any relatives who are presently, or who were formerly, employred by Smith's Drugs? Please list below
How were you referred to Smith's Drugs?
Have you ever been convicted of a felony?

Yes No
If yes, please explain

Educational History

	School Name	Years Completed	Diploma or Degree	Year Graduated/ Completed
High School
College
Graduate School
Technical Training
Other

Employment Record

Please list all employment for the last five years, with the most recent first. Use a separate sheet to list additional employers if necessary. Fill out any dates in the following format. MM/YY
Most Recent Employer
Name of Company
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Position
Start Date
MM/YY
End Date
MM/YY
Reason for Leaving
Manager
2nd Most Recent Employer
Name of Company
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Position
Start Date
MM/YY
End Date
MM/YY
Reason for leaving
Manager
3rd Most Recent Employer
Name of Company
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Position Held
Start Date
MM/YY
End Date
MM/YY
Reason for Leaving
Manager
Please enter any other employment below
References
1st Reference
Name
Phone Number

Area Code Phone Number
Years Known
Relationship
Occupation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
2nd Reference
Name
Phone Number

Area Code Phone Number
Years known
Relationship
Occupation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
3rd Reference
Name
Phone Number

Area Code Phone Number
Years Known
Relationship
Occupation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
If your application receives favorable consideration, when would you be available to work?
MM/DD/YY
Do you have any objection to working overtime?

Yes No
Do you have an objection to working on-call hours?

Yes No
Can you work Saturday?

Yes No
Can you work Sunday?

Yes No
Can you travel if required for this position?

Yes No
Do you have transportation back and forth from work?

Yes No
If you are finished High School, will you be continuing your education further?

Yes No
If your application received favorable consideration, what salary/hourly rate would you require?
$XX.XX/hr
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