PERSONAL INFORMATION
First Name
Last Name
Email
Home Phone
Cell Phn
Address
City
State
ZipCode
Transportation?
Do you have transportation? Yes No Substance tests
Are you willing to submit to and pass regularly scheduled controlled substance tests? Yes No Accommodation?
Are you able to perform the essential functions of the job for which you are applying, either with/without reasonable accommodation? Yes No If no, please describe
Note: Klingensmith’s Drug Store complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. A hire will be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.
Have you ever been convicted of a Criminal offense, Felony, or Misdemeanor?
Have you ever been convicted of a Criminal offense, Felony, or Misdemeanor? Yes No If yes, please describe
Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including, any significant details that affect the description of the event, and the surrounding circumstances, and the relevance of the offense to the position(s) applied for may, however, be considered.
Minors –
Work Permit?
Do you have a work permit?* Yes No If “NO”, please explain:
Can you work school nights?
Can you work school nights?* Yes No Unsure What time can you start on school days?
Do you have school activities that need considered?
Do you have school activities that need considered? * Yes No If “YES”, please explain:
EMPLOYMENT
Employment Desired
Position Applying for: (Select One) Pharmacist in Charge Staff Pharmacist Delivery Driver Sales Clerk / Fill-tech Data Entry Tech What Location
Select Desired Klingensmith Location*: (Select One) Ford City Kittanning Leechburg New Bethlehem NuMine Rimersburg West Kittanning Warehouse Not Applicable Desired Salary?
Are you looking for full-time employment?
Are you looking for Full-time or Part-time employment? Full-time Part-time Date available to begin*
Are you currently employed?
Are you currently employed? Yes No U.S. citizen or authorized
Are you a U.S. citizen or otherwise authorized to work in the U.S. on an unrestricted basis? Yes No EDUCATION
High School Name/Location
Years Attended
Year Graduated
College Name/Location
Years Attended
Year Graduated
Area of Study
Trade, Business, or Correspondence School
Years Attended
Year Graduated
Area of Study
Additional Skills, Qualifications, or Experience we should consider:
EMPLOYMENT HISTORY
EMP1-Name of Employer
EMP1-Name of Supervisor
EMP1-Type of Business
EMP1-Phone #
EMP1-Address
EMP1-City, State Zip code
EMP1-Length of Employment (Include Dates):
EMP1-Position and Duties:
EMP1-Reason for Leaving:
Employer 2
EMP2- Name of Employer
EMP2-Name of Supervisor
EMP2-Type of Business
EMP2-Phone #
EMP2-Address
EMP2-City, State Zip code
EMP2-Length of Employment (Include Dates):
EMP2-Position and Duties:
EMP2-Reason for Leaving:
Employer 3
EMP3-Name of Employer
EMP3-Name of Supervisor
EMP3-Type of Business
EMP3-Phone #
EMP3-Address
EMP3-City, State Zip code
EMP3-Length of Employment (Include Dates):
EMP3-Position and Duties:
EMP3-Reason for Leaving:
Add any additional work experience or certifications you feel we should consider:
PERSONAL REFERENCES
List three persons who have knowledge of your work experience within the last four years. Please include professional references only.
Reference 1
RE1- Reference 1 Name
RE1- Phone #
REF1 - Address
REF1 - City, State Zip code
REF1 - What Is The Relationship
REF1 - Number of Years Acquainted
Reference 2
REF2 - Name
REF2 - Phone #
REF2 - Address
REF2 - City, State Zip code
REF2 - What Is The Relationship?
REF2 - Number of Years Acquainted
Reference 3
REF3 - Name
REF3 - Phone #
REF3 - Address
REF3 - City, State Zip code
REF3 - What Is The Relationship?
REF3 - Number of Years Acquainted
RESUME' SUBMISSION
• IF APPLICABLE:
Separately submit your resume to Dina Blake at: dinab@klingsrx.com • Subject the email with your full name + resume. (i.e. John Doe - Resume)
Submit Application
