Fillable Printable Rite Aid Application Form

Rite Aid Application Form

NOTICES

Note to All Applicants Regarding Equal Employment Opportunity: We appreciate your interest in employment at Rite Aid Corporation.

Rite Aid is an equal employment opportunity employer. The Company’s policy is not to unlawfully discriminate against any applicant or

employee on the basis of race, color, sex, religion, national origin, age, disability, or any other basis protected by applicable federal, state, or

local laws. The Company also prohibits harassment of applicants and employees based on any of these protected categories.

Note to All Applicants Regarding Rite Aid’s Smoking Policy: Smoking is prohibited in all indoor areas of Rite Aid buildings unless

designated smoking areas have been established by a particular location in accordance with applicable state and local law.

Note to Rhode Island Applicants: Rite Aid is subject to Chapters 29-38 of Title 28 of the General Laws of Rhode Island, and is therefore

covered by the state’s workers’ compensation law.

Note to Massachusetts Applicants: Please initial the following statement to confirm that you are aware of its contents:

I understand that it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued

employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Initial Here: ________

Note to Maryland Applicants: Please initial the following statement to confirm that you are aware of its contents:

I UNDERSTAND THAT UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF

EMPLOYMENT, PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT ANY INDIVIDUAL SUBMIT TO OR TAKE A LIE

DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A

FINE NOT EXCEEDING $100.

Initial Here ________

A P P L I C A T I O N F O R E M P L O Y M E N T

P O S I T I O N A P P L I E D F O R

IF THIS APPLICATION IS FOR A MANAGEMENT POSITION CHECK HERE ❒

STORE MANAGER: Please forward MANAGEMENT APPLICATIONS to your Human Resources Manager.

Position ______________________________________________________ Location ________________________ Date you can start __________________________________

HOURS AVAILABLE

SUN MON TUE WED THU FRI SAT

MORNING

AFTERNOON

EVENING

P E R S O N A L

Name ___________________________________________________________________________________________________________________________________________

Last First Middle

Present Address ________________________________________________________________________ Telephone Number (Area Code) ( ______ ) ___________________

Street Address City State Zip Code

Do you have the legal right to work in the United States?

❒ Yes ❒ No Are you under the age of 18? ❒ Yes ❒ No

Have you ever worked under a different name?

❒ Yes ❒ No If yes, list name and location below

_____________________________________________________________________ ____________________________________________________________________________

Name Location

Form No. 21 Code No. 740416 (Rev. 5/11)

OVER

1. Have you ever visited a Rite Aid location? ❒Yes ❒ No If yes, where? ______________________________________ Describe your experience: ______________________

____________________________________________________________________________________________________________________________________________________

2. Why would you like to work for Rite Aid? _______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

3. Describe a specific situation where you have provided excellent customer service in your most recent position. _________________________________________________

______________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

4. Were you referred by a Rite Aid associate?

❒ Yes ❒ No If yes, name of associate: ____________________________________________________________________

5. Have you ever been dismissed or forced to resign from any employment?

❒ Yes ❒ No If yes, explain: ________________________________________________

_______________________________________________________________________________________________________________________________________

G E N E R A L I N F O R M A T I O N

Date (Month, Day, Year) _____________________________

E D U C A T I O N

NAME OF SCHOOL YEARS DIPLOMA OR DEGREE RECEIVED/ OVERALL

LOCATION (CITY, STATE, ZIP CODE) COMPLETED EXPECTED OR CREDITS EARNED GPA

HIGH SCHOOL

UNDERGRADUATE COLLEGE

GRADUATE COLLEGE

❒ MILITARY ❒ TRADE

OTHER

I certify that the above statements are true, and I understand that the making of false statements or omitting information will be considered

sufficient cause for immediate discharge upon discovery thereof. I understand that any employment offered to me will be on a probationary

trial basis. I further understand that unless specifically altered by a written employment contract, executed by an officer of the Company, my

employment will be terminable at will and at any time either by myself or Rite Aid. I authorize Rite Aid to make inquiry of any former employ-

ers or references as to my experiences, salary, character, habits, or reasons for leaving. If employed by the Company, I understand that I may

be required to submit to a drug test in accordance with Rite Aid’s drug testing policy.

Applicant’s Signature ___________________________________________________________________________ Date ________________________

RITE AID IS AN EQUAL OPPORTUNITY EMPLOYER

S T A T E M E N T O F A P P L I C A N T

California Applicants: Do not identify any misdemeanor conviction for which probation has been successfully completed or otherwise

discharged and the case has been dismissed by a court. Also, do not identify marijuana-related convictions entered by the court more

than 2 years ago that involve: unlawful possession of marijuana; transportation or giving away of up to 28.5 grams of marijuana, other

than concentrated cannabis, or the offering to transport or give away up to 28.5 grams of marijuana, other than concentrated cannabis;

possession of paraphernalia used to smoke marijuana; being in a place with knowledge that marijuana was being used; or being under the

influence of marijuana.

Connecticut Applicants: Do not identify any arrest, criminal charge or conviction the records of which have been erased by a court based

on sections 46b-146, 54 76o or 54-142a of the Connecticut General Statutes. Criminal records subject to erasure under these sections

are records concerning a finding of delinquency or the fact that a child was a member of a family with service needs, an adjudication as a

youthful offender, a criminal charge that has been dismissed or nolled (not prosecuted), a criminal charge for which the person was found not

guilty, or a conviction for which the offender received an absolute pardon. Any person whose criminal records have been judicially erased

under one or more of these sections is deemed to have never been arrested within the meaning of the law as it applies to the particular

proceedings that have been erased, and may so swear under oath.

District of Columbia Applicants: Do not identify convictions that were entered by the court more than 10 years ago.

Georgia Applicants: Do not identify any verdict or plea of guilty or nolo contendere that was discharged by the court under Georgia’s First

Offender Act.

Hawaii Applicants: Do not answer this question at this time. You will only have to answer this question if you receive a conditional offer of

employment. At that time you will be asked whether you have been convicted of a crime within the past ten (10) years, excluding any period

of time when you were in jail.

Massachusetts Applicants: Do not answer the following question.

Michigan Applicants: Do not identify any pending misdemeanor charges.

Nevada Applicants: You need only disclose convictions for felonies, and within the last 7 years, misdemeanors which resulted in

imprisonment. In addition, the discharge and dismissal of certain first time drug offenses, after the accused has completed probation and

any required treatment or educational programs, does not constitute a conviction for purposes of employment. An applicant may not be held

guilty of perjury or for giving a false statement for failing to acknowledge or disclose the arrest, indictment or trial in response to any inquiry.

New York Applicants: You may answer “no record” concerning any criminal proceeding that terminated in your favor, per section 160.50

of the New York Criminal Procedure Law; any criminal proceeding that terminated in a “youthful offender adjudication,” as defined in section

720.35 of the New York Criminal Procedure Law; and any conviction for a “violation” that already has been sealed by the court, per section

160.55 of the New York Criminal Procedure Law.

Ohio Applicants: Do not include convictions for minor misdemeanor drug violations pursuant to Ohio Revised Code §2925.11.

Pennsylvania Applicants (City of Philadelphia ONLY): Do not answer the following question.

Washington Applicants: Do not identify any conviction that is more than ten (10) years old at the time of making this application, unless

some period of incarceration resulting from that conviction took place within the last 10 years

HAVE YOU EVER BEEN CONVICTED OF A FELONY OR MISDEMEANOR WHICH HAS NOT SINCE BEEN PLACED UNDER SEAL OR

EXPUNGED? ❒ YES ❒ NO IF YES, PLEASE EXPLAIN THE NATURE OF THE CRIME(S) AND THE DATE(S) OF THE CONVICTION(S).

______________________________________________________________________________________________________________________________

NOTE: (A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU FROM THE JOB FOR WHICH YOU HAVE APPLIED)

C O N V I C T I O N S

P H A R M A C I S T S , P H A R M A C Y T E C H N I C I A N S & P H A R M A C Y I N T E R N S O N LY

Registered States

________________ License Number ______________________________________

Have you ever had or do you currently have any restrictions on your license?

❒ Yes ❒ No

If yes, explain below.

_____________________________________________________________________________________________________________________________________________________

EMPLOYER AND LOCATION POSITION TITLE AND STARTING RATE REASON FOR

STREET ADDRESS, CITY, STATE, ZIP IMMEDIATE SUPERVISOR ENDING RATE LEAVING

FROM MO/YR EMPLOYER (present or most recent) YOUR TITLE $

______________ ADDRESS SUPERVISOR

TO MO/YR

MAY WE CONTACT?

❒ YES ❒ NO $

TELEPHONE NUMBER

______________

FROM MO/YR EMPLOYER YOUR TITLE $

______________ ADDRESS SUPERVISOR

TO MO/YR

MAY WE CONTACT?

❒ YES ❒ NO $

TELEPHONE NUMBER

______________

FROM MO/YR EMPLOYER YOUR TITLE $

______________ ADDRESS SUPERVISOR

TO MO/YR

MAY WE CONTACT?

❒ YES ❒ NO $

TELEPHONE NUMBER

______________

FROM MO/YR EMPLOYER YOUR TITLE $

______________ ADDRESS SUPERVISOR

TO MO/YR

MAY WE CONTACT?

❒ YES ❒ NO $

TELEPHONE NUMBER

HAVE YOU EVER WORKED FOR RITE AID?

❒ Yes ❒ No

IF YES DATES OF EMPLOYMENT __________________________________________ REASON FOR LEAVING _______________________________________________________

______________________________________________________________________________________________________________________________________________________

E M P L O Y M E N T & E X P E R I E N C E