Physicians’ Choice Infusion Pharmacy
1.800.208.6294
Compounding@pcipharmacy.com
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Application for Employment
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Date
Position applying for
Personal Data
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Name (last, first, middle)
*
List all other names you may have used in the past (Including maiden name, if applicable)
Date of Birth
*
Address
Address Line 1
City
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Have you lived in any other county(s) or state(s) other than the one you currently reside in? If so, list:
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Home Telephone Number
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Business Telephone Number
Cellular Telephone Number
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Date you can start work
Social Security No
Email Address
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Position applied for
Salary Pay Range Expected
(be Specific)
Days Available to Work
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours available to work
If needed, can you be “ON CALL” on night and weekends?
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Employment Desired
Full-Time Only
Part-Time Only
Full or Part Time
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If applicable, do you have to provide your current job notice of resignation?
Yes
No
When are you available to start work?
Note:
Have you been terminated from a position for “cause” ?
Yes
No
If so, explain
Have you ever been “layed off” from a position?
Yes
No
If so, explain
Are you authorized to work in the U.S. on an unrestricted basis?
Yes
No
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Have you ever been arrested?
Yes
No
If so, explain
Have you ever been convicted of misdemeanor or a felony?
Yes
No
If so, explain
QUALIFICATIONS
- Please list any education or training better that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military training.
School Details
School Name
Standard/Degree
Address/City/State
Year
College Details
College Name
Degree
Address/City/State
Year
Others
College Name
Degree
Address/City/State
Year
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DRIVING LICENSE
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DRIVER LICENSE NUMBER
NUMBER
Do you have a driver’s license in the state of TX?
Yes
No
Number
What is your means of transportation to work
Have you had a driver’s license in other states? If so, list
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Have you had any accidents or moving violations in the last 3 years ?
How Many?
If so, explain
CERTIFICATIONS, SPECIAL SKILLS
REFERENCES
Please list four professional references not related to you, with full name, address, phone number, and relationship. If you don’t have four professional references, then list personal, unrelated references.
References1
Name
Relationship
Email Address
Phone Number
References 2
Name
Relationship
Email Address
Phone Number
References 3
Name
Relationship
Email Address
Phone Number
References 4
Name
Relationship
Email Address
Phone Number
References 5
Name
Relationship
Email Address
Phone Number
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WORK HISTORY
Start with your current or most recent position. Use separate sheet if necessary. (INCLUDE PAID AND UNPAID POSITIONS)
Work 1
Job Title #1
Company Name
Supervisor Email
Reason for Leaving
Starting Salary
List Duties:
Start Date (mo/day/yr)
End Date (mo/day/yr)
Hours worked
Supervisor’s Name
Ending Salary
Phone Number
Address
City
Zip Code
May we contact your employer?
Yes
No
Work 2
Job Title 2
Company Name
Supervisor Email
Reason for Leaving
Starting Salary
List Duties:
Start Date (mo/day/yr)
End Date (mo/day/yr)
Hours worked
Supervisor’s Name
Ending Salary
Phone Number
Address
City
Zip Code
May we contact your employer?
Yes
No
Work 3
Job Title 3
Company Name
Supervisor Email
Reason for Leaving
Starting Salary
List Duties:
Start Date (mo/day/yr)
End Date (mo/day/yr)
Hours worked
Supervisor’s Name (copy)
Ending Salary
Phone Number
Address
City
Zip Code
May we contact your employer?
Yes
No
Next
Work 4
Job Title 4
Company Name
Supervisor Email
Reason for Leaving
Starting Salary
List Duties:
Start Date (mo/day/yr)
End Date (mo/day/yr)
Hours worked
Supervisor’s Name
Ending Salary
Phone Number
Address
City
Zip Code
May we contact your employer?
Yes
No
Upload Your Resume
Click or drag a file to this area to upload.
I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that any and all false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the information set forth in this application and release the Employer from any liability. This can include education verification, arrest records, criminal convictions and motor vehicle records. I authorize, without reservation, any party or agency contacted by the company to furnish the above-mentioned information prior to or at any time during my employment. The information on this form will be used solely for the purpose of conducting background checks to determine employment eligibility and will be held in strict confidence. The employer may contact any listed references on this application.
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