Employment Application

We consider applicants for all positions without regard to race, color, religion, creed, gender, age, or any other protected status.

Name

Last Name: *

First Name: *

Middle Initial:

Address

Address: *

City: *

State: *

Zip: *

Phone

Daytime Phone Number: *

Evening Phone Number: *

Are you prevented from lawfully becoming employed in the U.S.A. because of Visa or Immigration Status?: *

Position

Position Applying For: *

Today's Date: *

Salary Hours

Desired Salary: *

Hours available to work: *

Availablility

Date Available: *

Available: *

Do any of your friends or relatives work for Mina Pharmacy?: *

Provide Names 1

If yes, please provide name of friend or relative and store location.

Name #1:

Store Location #1:

Provide Names 2

Name #2:

Store Location #2:

Provide Names 3

Name #3:

Store Location #3:

Current Employ

Are you currently employed?: *

May we contact your present employer?: *

Past Employers

PAST EMPLOYERS (Please list most recent first.)

Employer #1:

Employer #1 Address

Address:

City:

State:

Zip:

Employer #1 Phone Supervisor

Phone Number:

Supervisor:

Employer #1 From To

Date From:

Date To:

Employer #1 Start End Title

Start Job Title:

End Job Title:

Employer #1 Start End Salary

Start Salary:

End Salary:

Duties:

Reason for Leaving:

Employer #2:

Employer #2 Address

Address:

City:

State:

Zip:

Employer #2 Phone Supervisor

Phone Number:

Supervisor:

Employer #2 From To

Date From:

Date To:

Employer #2 Start End Title

Start Job Title:

End Job Title:

Employer #2 Start End Salary

Start Salary:

End Salary:

Duties:

Reason for Leaving:

Employer #3:

Employer #3 Address

Address:

City:

State:

Zip:

Employer #3 Phone Supervisor

Phone Number:

Supervisor:

Employer #3 From To

Date From:

Date To:

Employer #3 Start End Title

Start Job Title:

End Job Title:

Employer #3 Start End Salary

Start Salary:

End Salary:

Duties:

Reason for Leaving:

Education

EDUCATION (Please list most recent first.)

Education #1:

Education #1 Address

Address:

City:

State:

Zip:

Education #1 Years

Years Completed:

Year of Graduation:

Courses Studied:

Education #2:

Education #2 Address

Address:

City:

State:

Zip:

Education #2 Years

Years Completed:

Year of Graduation:

Courses Studied:

Education #3:

Education #3 Address

Address:

City:

State:

Zip:

Education #3 Years

Years Completed:

Year of Graduation:

Courses Studied:

OTHER JOB RELATED SKILLS:

(Please list if you can speak, write, and/or read other languages besides English.)

COMMENTS:

(Include explanation of any gaps in employment.)

References #1 Name & Phone

REFERENCES

Name #1:

Phone Number:

References Employer #1 & Job Title

Employer:

Job Title:

References #2 Name & Phone

Name #2:

Phone Number:

References Employer #2 & Job Title

Employer:

Job Title:

References #3 Name & Phone

Name #3:

Phone Number:

References Employer #3 & Job Title

Employer:

Job Title:

I acknowledge that all information provided on this application is accurate and true to the best of my knowledge.

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