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Demographic Information

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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 *

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? *

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

Are you 18 years of age or older? *

Are you legally eligible to work in this country? *

Will you travel if the job requires it? *

Will you work overtime if required? *

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

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? *

If yes, how many?

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

If yes, how many?

Education

High School

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If you are licensed, has your license ever been revoked or suspended or are you currently involved in any proceeding that could affect your license or certification?

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

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

Have you ever been terminated from a previous position?

If yes, please explain.

References

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?

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?

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?

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?

If yes, please list them.

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