Mrs. Mr. Miss Ms.      

  IA NE SD  

Social Security Number (optional) Note: background check will be completed before hiring.  Must be at least 18 years of age or older for this position and have a valid driver's license.

Have you filed an application with Maier Pharmacy before? No Yes

Have you every worked for Maier Pharmacy before? No Yes

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? No Yes   (Proof of citizenship or immigration status will be required upon employment)

On what date would you be available for work

Are you available to work Part-time Full-time Shift-work Temporary

Are you employed now? Yes No   If (Yes) may we contact your current employer? Yes No

Can you travel if your job requires it? Yes No

Have you been convicted of a felony within the last 7 years? No Yes

(Conviction will not necessarily disqualify applicant from employment)

If Yes, please explain:

Are you a military veteran? No Yes

Languages you can speak, read and/or write? English Spanish Other

List professional, trade, business or civic activities and offices held. You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, handicap or other protected status.

Education level achieved High School Graduate Some College Tech/Trade School Graduate College Graduate Graduate/Professional Degree

List any special honors received, type of degree or specialized training received:

Employment Experience: Start with most recent and go back in time

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List the name and phone #'s of three references who are not relatives and who you haven't worked for:

Why would you like to work for Maier Family Pharmacy and what special skills and qualifications do you think could benefit our company?

By submitting this form, you certify that answers given herein are true and complete to the best of your knowledge and authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

The applicant understands that neither this document nor any offer of employment from the employer constitute an employment contract unless a specific document to that effect is executed by the employer and employee in writing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

You will be required to sign a printed version of this form at the time of interview or employment.

Please enter your E-mail Address: