Emergency Contact Information
Person to notify in case of emergency
Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment)
Are you at least 18 years or older? (If no, you may be required to provide authorization to work)
Have you ever been convicted of a felony or a misdemeanor which resulted in imprisonment within the last five years? (A conviction will not necessarily result in the denial of employment)
If Yes, please explain.
Have you ever worked for this Company before? Yes No
If Yes, please provide details (Where/ When/ Job Title)
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation? Yes No
If no, please explain.
If presently employed, why are you considering leaving?
List any Experience and Training that may qualify you to work for us:
If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:
Employment History (starting with current or most recent employment)
Personal References: Other Than Relatives
Additional education information
Equal Opportunity Employment
WE ARE AN EQUAL OPPORTUNITY EMPLOYER AND DO NOT DISCRIMINATE ON THE BASIS OF RACE, ANCESTRY, COLOR, RELIGION, SEX, AGE, MARITAL STATUS, SEXUAL ORIENTATION, NATIONAL ORIGIN, MEDICAL CONDITION, DISABILITY, VETERAN STATUS, OR ANY OTHER BASIS PROTECTED BY LAW. THE INFORMATION PROVIDED WILL BE USED FOR RESEARCH, REPORTING, STATISTICAL PURPOSES AND TO MONITOR LEGAL COMPLIANCE. TO HELP US COMPLY WITH THESE GOVERNMENT REQUIREMENTS, PLEASE COMPLETE THE FOLLOWING INFORMATION. COMPLETION OF THIS FORM IS VOLUNTARY AND WILL NOT AFFECT YOUR OPPORTUNITY FOR EMPLOYMENT OR TERMS OR CONDITIONS OF EMPLOYMENT IF HIRED. WE APPRECIATE YOUR COOPERATION.
PLEASE READ BEFORE SIGNING
If I misrepresent or deliberately leave out a fact in my application, I may be refused employment or, if employed, I may be terminated.
The Company has my authorization to investigate my work, medical and personal history that is job related. I will hold no person corporation or organization liable for giving or receiving information In this investigation. Upon termination of my employment, I authorize the company to disclose the Company's reason or understanding for my termination, unless I have requested in writing that no such disclosure be made. I hereby waive and release any claims I may have as a result of the communication or disclosure of any information relating to my employment or its termination.
I understand and agree that neither this application nor any other Company documents (now or in the future) are a contract of employment, and further, that if employed, my employment may be terminated by the Company, or I may terminate my employment with the Company, at any time: with or without cause, and without notice. The Company is liable only for wages and salary earned as of the date of termination. I also authorize the Company to deduct at any time any monies owed by me to the Company at the time of termination. I further acknowledge that any offer of employment, or my acceptance of any offer, may be withdrawn with or without cause of prior notice, by either me or the Company.
Any doctor, hospital or testing laboratory may conduct medical tests, including but not limited to drug testing, and I hereby give my consent to having all information released necessary for the Company to determine my abilities to perform job duties now or in the future.
I understand that no representative or supervisor of the Company, other than the President by acknowledgment in writing, has any authority to enter into any agreement, express or implied, or to make any agreement contrary to the foregoing, or to assure any specific benefits, terms or conditions of employment.
NOTICE OF DISPUTE RESOLUTION PROGRAM
The Drug Emporium Dispute Resolution Program ("Program") requires that any dispute between me and Drug Emporium that is covered under the Program, or any covered employment-related claim by either of us against the other, must be resolved through internal company procedures or through mediation or
. final and binding arbitration NO SUCH DISPUTE OR CLAIM CAN BE TAKEN TO COURT OR HEARD BY A JURY. This includes, but is not limited to, any covered claim or dispute I might have involving a Company officer, director, owner, associate, representative, or agent. It also includes, but is not limited to, any claim based upon a failure or refusal to hire. I understand that a copy of the complete Program booklet will be provided to me prior to beginning work for the Company. I understand that my use of this Program is a mandatory condition of my employment (for all new employees, other than pharmacist, hired on or after June 1, 1999), which I accept and agree to by signing a "Receipt and Agreement" form provided by the Company, receiving a copy of the Program booklet and becoming employed by the Company. If I fail to comply with the Program or any policy or procedure described in the Employee Handbook, my employment may be terminated. Even if my employment is terminated (voluntarily or involuntarily, for any reason), the Program will continue to apply.
I have read, understand and agree to the above and hereby certify that the facts I have provided in my employment application are true and complete.
This application is current and active for only three (3) months, at the conclusion of which time if I still wish to be considered for employment, I will submit a new application.
U.S. law requires that, if hired, you must have a social security card, along with additional documentation to establish your eligibility for employment. A list of acceptable documents are available, upon request.