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.
* Required
Contact Information & Demographics
Full Name?
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Your answer
Address?
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Your answer
City, State ZIP?
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Your answer
E-mail Address?
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Your answer
Phone Number?
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Your answer
Gender?
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Male
Female
I Choose Not to Disclose
Race/Ethnicity
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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?
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Yes
No
I Choose Not to Disclose
Veteran Status
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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?
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Yes
No
Do you agree to be tested for drugs and/or alcohol as permitted by law and may be required of employees per company policy?
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Yes
No
Are you willing to submit to a criminal background check?
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Yes
No
Are you 21 years of age or older?
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Yes
No
If you answered NO to the previous question, please provide your date of birth.
MM
/
DD
/
YYYY
Position and Availability
What type of position are you applying for?
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Choose
Pharmacist
Technician
Clerk
Office Assitant
Facilities Management/Delivery Service
What type of a position are you interested in?
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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?
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Yes
No
Are you available to work some holidays?
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Yes
No
When are you available to start work?
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MM
/
DD
/
YYYY
Education
Select all that applies to you.
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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?
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Yes
No
Other:
Do you speak and understand Spanish?
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Yes
No
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)
Your answer
Registered Pharmacist License #2 [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)
Your answer
Registered Pharmacist INTERN License [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)
Your answer
Pharmacy Technician License #1 [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)
Your answer
Pharmacy Technician License #2 [STATE (i.e. NM), NUMBER, EXPIRATION (mm/dd/yyyy) ? (if applicable)
Your answer
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.
Your answer
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.
Your answer
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.
Your answer
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
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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?
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If Yes, Please Explain in "Other"
Yes
No
Other:
Have you ever been the subject of a pharmacy related license suspension, revocation, or other adverse action by any licensing authority?
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If Yes, Please Explain in "Other"
Yes
No
Other:
Have you had any pharmacist, intern or technician license sanctioned?
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If Yes, Please Explain in "Other"
Yes
No
Other:
Other
Please provide any other information that you find relevant to your application below.
Your answer
Submit
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