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? *
Race/Ethnicity *
Have you served in the US Armed Forces? *
Veteran Status *
Policy Disclosures
Do you have legal authorization to work in the USA? *
Do you agree to be tested for drugs and/or alcohol as permitted by law and may be required of employees per company policy? *
Are you willing to submit to a criminal background check? *
Are you 21 years of age or older? *
If you answered NO to the previous question, please provide your date of birth.
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Position and Availability
What type of position are you applying for? *
What type of a position are you interested in? *
Are you available to work weekends? *
Are you available to work some holidays? *
When are you available to start work? *
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Education
Select all that applies to you. *
Required
Do you speak and understand English? *
Do you speak and understand Spanish? *
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
Technician Certifications
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
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 #3
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.
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 *
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"
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"
Have you had any pharmacist, intern or technician license sanctioned? *
If Yes, Please Explain in "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..