Pharmacist Employment Eligibility & Verification Form

PRS Pharmacy Services is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state or federal law. Should an applicant need reasonable accommodation in the application process, s/he should contact a company representative.

PERSONAL INFORMATION

Name

Current Address

City

State

Zipcode

Primary Phone

Alternate Phone

Email

Have You Ever Been Employed By PRS?

Yes No

If Yes, When

Position You Are Applying For

Date Available For Work

CURRENT (OR MOST RECENT) EMPLOYER

May We Contact Your Current Or Most Recent Employer?

Yes No

Employer Name

Name/Title of Supervisor

Phone

Employer Address

Employer City

Employer State

Employer Zipcode

Employment Dates

Work Status

Position Held

Reason For Leaving

STATE LICENSURE

Please List All Relevant License Numbers and Corresponding States

EMPLOYMENT ELIGIBILITY

Are you authorized to work in the United States?

Yes No

Are you subject to a non-compete agreement, even if it may not be related to the position you are applying for?

Yes No

Can you, with or without reasonable accommodation, perform the specific job functions of the position for which your are applying?

Yes No

Are you currently excluded or aware of any potential exclusion from a federally funded healthcare program, including Medicare and Medicaid?

Yes No

UPLOAD RESUME

Upload your resume to help expedite the application process. This is a required action as part of your submission.

Accepted file types: PDF, DOC, DOCX
Max file size is 10MB

I CERTIFTY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I UNDERSTAND THAT UNREQUESTED INFORMATION, FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACTS ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) MAY BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Initials (Signature)

Full Legal Name

Date

PRS Pharmacy Services provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, marital status, national origin, age, disability, pregnancy, genetic information, veteran status or any other status protected by law.