Roden-Smith Pharmacy Employment Application

Please provide Contact Information, Availability, Education, Credentials, Work Experience and additional information below. Roden-Smith Pharmacy is an equal employment opportunity employer and as such you are protected from discrimination based on race, color, religion, sex, national origin, disability, age, genetics, from retaliation and all other items enumerated by the law. Some questions found below indicate an option to not answer as " I choose not to disclose ". These items are collected solely for reporting purposes and you do not have to provide an answer to these questions.

Contact Information & Demographics

Full Name? *

Address? *

City, State ZIP? *

E-mail Address? *

Phone Number? *

Gender? *

Male

Female

I Choose Not to Disclose

Race/Ethnicity *

Asian

American Indian or Alaskan Native

Black or African American

Hispanic/Latino

Native Hawaiian or Other Pacific Islander

White (Not Hispanic or Latino)

Two or More Races

I Choose Not to Disclose

Have you served in the US Armed Forces? *

Yes

I Choose Not to Disclose

Veteran Status *

I AM a Protected Veteran

I am NOT a Protected Veteran

I Choose Not to Disclose

Policy Disclosures

Do you have legal authorization to work in the USA? *

Yes

Do you agree to be tested for drugs and/or alcohol as permitted by law and may be required of employees per company policy? *

Yes

Are you willing to submit to a criminal background check? *

Yes

Are you 21 years of age or older? *

Yes

If you answered NO to the previous question, please provide your date of birth.

YYYY

Position and Availability

What type of position are you applying for? *

What type of a position are you interested in? *

Any Available Position

Full Time (32 hrs or more per week w/ Full Time Benefits)

Part Time (Less than 32 hours per week)

Internship

Are you available to work weekends? *

Yes

Are you available to work some holidays? *

Yes

When are you available to start work? *

YYYY

Education

Select all that applies to you. *

Currently Attending High School

High School Diploma

Currently Attending College

Some College Completed (not currently attending)

Associates Degree

Bachelors Degree

Masters Degree

Currently Attending Pharmacy School

Bachelors in Pharmacy (B.S. Pharmacy)

Pharmacy Doctorate (Pharm.D.)

Other:

Required

Do you speak and understand English? *

Yes

Other:

Do you speak and understand Spanish? *

Yes

Other:

Licenses Held

This section may not apply to you and can be left blank if you are not a licensed technician, intern or pharmacist.

Registered Pharmacist License #1 [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)

Registered Pharmacist License #2 [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)

Registered Pharmacist INTERN License [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)

Pharmacy Technician License #1 [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)

Pharmacy Technician License #2 [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)

Certifications Held

Select categories for which you hold additional certifications

Pharmacists Certifications

Compounding (Non-Sterile)

Compounding (Sterile)

Diabetes

Emergency Contraception

Immunizations

Naloxone Prophylaxis

Smoking Cessation

TB Testing

Other:

Technician Certifications

Certified Pharmacy Technician (CPhT via PTCB)

Compounding (Non-Sterile)

Compounding (Sterile)

Other:

Work Experience

Please list your 3 most recent work experiences. If none, then indicate as such.

Work Experience #1

Please indicate Company Name, City, State, Supervisor Name, Supervisor Phone #, Dates Worked (i.e. mm/yyyy -mm/yyyy), Position Held, Rate of Pay (i.e. $/hr, $/yr salary, etc.), and Reason for Leaving. Also, enter "May Contact" if it is alright for us to contact your previous supervisor.

Work Experience #2

Work Experience #3

References

Please indicate "Yes" below if during the interview process you would be able to provide contact information for 1-2 References if requested to do so by pharmacy management.

References *

YES, If requested I can provide reference information.

NO, If requested I would not be able to provide references.

Other:

Additional Questions

Are you currently, or have you ever been investigated for program-related fraud or patient abuse, licensing board actions, or default on Health Education Assistance Loans? *

If Yes, Please Explain in "Other"

Yes

Other:

Have you ever been the subject of a pharmacy related license suspension, revocation, or other adverse action by any licensing authority? *

If Yes, Please Explain in "Other"

Yes

Other:

Have you had any pharmacist, intern or technician license sanctioned? *

If Yes, Please Explain in "Other"

Yes

Other:

Other

Please provide any other information that you find relevant to your application below.

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This form was created inside of Roden-Smith Pharmacy / Blackwater Coffee Co..