Fillable Printable Pharmacy Application for Employment
Fillable Printable Pharmacy Application for Employment
Pharmacy Application for Employment
PHARMACIST APPLICATION FOR EMPLOYMENT
Name
Title
(RPh,PharmD etc)
Street
City
State Zip
Date of Birth
/ /
Social Security Number
-
-
e-Mail Address
Home Phone
Work Phone
Cell Ph one
FAX:
I prefer to be contacted via
Home Phone Cell phone Work Phone e-Mail
AM PM
State License(s):
State License No. State License No. State License No.
State License No.
State License No.
State License No.
Have you ever been convicted of a felony?
YES NO
Are you a citizen of the United States? YES NO
If not, are you eligible t o legally work in the United States? YES NO
INDEMNIFICATION & HOLD HARMLESS AGREEMENT
As an independent contractor I agree that I shall indemnify, hold and save harmless, and defend, at my own
expense, Pharmacy Resources Network, its officials, agents, employees, and clients, from and against all
suits, claims, demands, and liability of any nature or kind, including their costs and expenses, arising out of
acts or omissions by me, the independent contractor, including claims and liability in the nature of workmen's
compensation, in the performance of my duties scheduled through Pharmacy Resources Network. I agree
that the obligations under this agreement do not lapse upon termination of association with Pharmacy
Resources Network.
As an independent contractor I also agree to provide and thereafter maintain liability insurance in an adequate
amount to cover third party claims for death or bodily injury, arising from or in connection with the provision of
services contracted through Pharmacy Resources Network.
Signature__________________________________________ Date ____________________
PLEASE NOTE:
We are contractually obligated to keep on file a copy of your state pharmacy license(s), your
malpractice/liability insurance card or certificate, and your drivers license. These copies, as well as a copy of
your resume including two references from licensed pharmacists, must be provided prior to working for our
company. There may be additional documentation requirements, depending on specific clients with which you
may schedule.
Health Research Associates, Corp. 877.797.9470 (Toll free office)
d/b/a Pharmacy Resources Network, Inc. 866.225.3430 (Toll free fax)
Post Office Box 1233 2959 Cherokee Street Suite 203
Kennesaw, GA 30156-8233 Kennesaw, GA 30144-6522
PHARMACIST APPLICATION FOR EMPLOYMENT –PART 2
Name _________ _______________ _______________________
Some of our clients require additional information before we may place you in a relief
engagement in their pharmacies. To insure your eligibility to be assigned to any of our client
pharmacies please complete the additional information below:
Please provide the following:
Residence address es for the last 5 years:
From ____/____/____ To ____/____/____
1
Street
City State Zipcode
From ____/____/____ To ____/____/____
2
Street City
City Zipcode
From ____/____/____ To ____/____/____
3
Street City
State Zipcode
Pharmacy Employment (as A Registered Pharmacist) for the last 5 years:
From ____/____/____ To ____/____/____
1
Pharmacy
City State Zipcode
From ____/____/____ To ____/____/____
2
Pharmacy City
City Zipcode
From ____/____/____ To ____/____/____
3
Pharmacy City
State Zipcode
Education: Please provide Educational Institutions, Degree and Da te conferred:
From ____/____/____ To ____/____/____ Date of Degree ____/____/____
1
School/Institution
City State DEGREE
From ____/____/____ To ____/____/____ Date of Degree ____/____/____
2
School/Institution
City
City DEGREE
From ____/____/____ To ____/____/____ Date of Degree ____/____/____
3
School/Institution
City
State DEGREE
Certifications: Other than Lic. or Degrees specified above, please pro vid e any special certification(s)
Type of Certification Reg/Cert Number State Expiration Date
1
2
3
4
PHARMACIST PROFILE INFORMATION PART 3
Name _________ _______________ _______________________
This information is Optional, but would help us in planning, trai ning, and finding shifts that match
your skills and background as a Pharmacist. Please complete as much of the additiona l
information belo w as possible:
Pharmacy Experience:
Retail
Hospital
Long Term Care
PharmD
Nursing Home
Government
Home Infusion
Compounding
IV
Other _____ ____________
Preferences:
Settings in which y ou would like to be placed:
Retail
Hospital
Long Term Care
Computer Systems Experience:
PDX
Zadall
QS-1
Rx2000
NDC
Other___________________
Other _____ ______________
