Employment Application – DrugCo Pharmacy

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Employment Application

Drugco Discount Pharmacy is an equal opportunity employer and we do not discriminate in hiring based on color, race, religious creed, national origin, age, sex, or any physical or mental handicap that does not relate to the ability to perform the essential functions of the job.

If you are human, leave this field blank.

Demographic Information

Today's Date *

Date Available to Start *

Name (Last, First, Middle Initial) *

Address (No PO Box) *

Country

City

State

Zip code

Social Security Number *

Date of Birth *

Phone Number *

Email Address *

Employment Desired

Position Applied For *

Full/Part Time *

Full Time

Part Time

Work Site Preferred (can select multiple) *

Roanoke Rapids

Express

Nashville

Tarboro

Lake Gaston

Ahoskie

Work Schedule Preferred (can select multiple) *

First shift

Second shift

Third shift

Rotating

Weekends

Have you ever submitted an application with Drugco Discount Pharmacy before? *

Yes

No

Have you ever been employed by Drugco Discount Pharmacy before? *

Yes

No

Are you 18 years of age or older? *

Yes

No

Are you legally eligible to work in this country? *

Yes

No

Will you travel if the job requires it? *

Yes

No

Will you work overtime if required? *

Yes

No

Have you ever been convicted of or entered a plea of guilty, no consent, or had a withheld judgement to a felony? *

Yes

No

If yes, please explain.

What is your desired range of hourly rate of pay? *

Please list your driver’s license number. *

State (Driver's License) *

Have you had an accident in the past three years? *

Yes

No

If yes, how many?

Have you had any moving violations in the past three years? *

Yes

No

If yes, how many?

Education

High School

GED

Name of School, Location (City, State), Diploma/Certificate Received

College

Name of School, Location (City, State), Diploma/Certificate Received

Other

Name of School, Location (City, State), Diploma/Certificate Received

If you are licensed, has your license ever been revoked or suspended or are you currently involved in any proceeding that could affect your license or certification?

Yes

No

Are you a member of any professional organizations? If so, please list.

Honors received, volunteer or community service, or other qualifications you have that you feel would make you a good candidate for the position which you are applying for

Have you ever been terminated from a previous position?

Yes

No

If yes, please explain.

References

Reference name and phone number *

Reference name and phone number *

Employment History

Please begin by listing your most current employer and continue with the most recent employers.

Employer/Company, Address (City, State), Position Held, Supervisor’s Full Name, Phone Number (please include area code), Dates Employed, Compensation, Reason for Leaving

May we contact for reference?

Yes

No

Employer/Company, Address (City, State), Position Held, Supervisor’s Full Name, Phone Number (please include area code), Dates Employed, Compensation, Reason for Leaving

May we contact for reference?

Yes

No

Employer/Company, Address (City, State), Position Held, Supervisor’s Full Name, Phone Number (please include area code), Dates Employed, Compensation, Reason for Leaving

May we contact for reference?

Yes

No

Please explain any gaps in employment other than those due to illness, injury, or disability.

Do you speak, write, or read any languages other than English?

Yes

No

If yes, please list them.

Captcha *

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