Basic Employment Application Form

Employment Application BrickStreet Pharmacy is an equal opportunity employer. Equal access to the hiring process, services, and employment is available to all individuals. Applicants requiring accommodations to the application and/or interview process should contact the Human Resource Representative. Each question should be answered completely and accurately. No action will be taken on this application until all questions have been answered and the application has been signed and dated. Verification of eligibility to work in the U.S. will be required if an employment offer is made.

Full Name*

First NameLast Name

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

Confirmation Emailexample@example.com

Position(s) applying for*

Wage expectations*

Salary or Hourly?*

Referral source

Are you over the age of 18?*

YESNO

Are you eligible to work in the United States?*

YESNO

Are you fluent in a foreign language?*

YESNO

If yes, what language(s)?*

Are you currently employed?*

YESNO

Date available for work*

Date

Are you available to work?*

Full timePart timeShift workTemporary

Have you applied here before?*

YESNO

If yes, give date:*

Have you been convicted of a felony/misdemeanor (other than traffic violations)?*

YESNO

If so, provide the location, date and result/outcome for each conviction:*

EDUCATION

Highest level of education completed:*

Please complete the appropriate sections

	Name & Location of School	Number of Years Attended	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

WORK HISTORY Please list your four most recent employers, list the most recent first

1. Employer

Employer's Name (Most current)*

Address & location of business*

Your title*

May we contact this employer?*

YESNO

Supervisor's name*

First and Last Name

Phone number*

Start date*

MonthDayYear

End date

MonthDayYear

Wages START:*

Salary or Hourly*

Wages END:*

Salary or Hourly*

Work performed:*

Reason for leaving*

2. Employer

Employer's Name (Second most recent)*

Address & location of business*

Your title*

May we contact this employer?*

YESNO

Supervisor's name*

First and Last Name

Phone number*

Start date*

MonthDayYear

End date

MonthDayYear

Wages START:*

Salary or Hourly*

Wages END:*

Salary or Hourly*

Work performed:*

Reason for leaving*

3. Employer

Employer's Name (Third most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Start date

MonthDayYear

End date

MonthDayYear

Wages START:

Salary or Hourly

Wages END:

Salary or Hourly

Work performed:

Reason for leaving

4. Employer

Employer's Name (Fourth most recent)

Address & location of business

Your title

May we contact this employer?

YESNO

Supervisor's name

First and Last Name

Phone number

Start date

MonthDayYear

End date

MonthDayYear

Wages START:

Salary or Hourly

Wages END:

Salary or Hourly

Work performed:

Reason for leaving

ADDITIONAL INFORMATION

Do you have a U.S. military service record?*

YESNO

Click to edit

If yes, branch of service*

Discharge date and rank*

List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)

List any additional information you would like us to consider:

REFERENCES List three professional references, (business or work, not relatives) that you have known for at least one year. List at least one previous supervisor.

1. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

2. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

3. Full Name*

First NameLast Name

Company*

Best phone number to reach them*

Years acquainted*

Relationship*

AUTHORIZATION I understand that Scott HR LLC is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination, if employed. I authorize Scott HR LLC to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, credit history, driving record, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to Scott HR LLC. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original. Pre-employment testing may be required (drug testing, background checks, physical examinations, motor vehicle checks).Testing may be applicant or employer paid based on the employer.I understand that any offer of employment may be withdrawn if drug tests are positive and/or if a condition is discovered for which no reasonable accommodation can be made. I understand that this application is current for 60 days. At the conclusion of this time, if I have not heard from Scott HR LLC and still wish to be considered for employment, it will be necessary to complete a new application. I understand that if hired, employment is at-will, regardless of the employer, and may be terminated by myself, the employer or Scott HR LLC at any time, with or without cause or notice, for any reason or no reason.

By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree

You must agree to accept the terms of the document in order to submit an application.

Type signature*

Date*

Date

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