Career Opportunities Form

Birth Date

Full Name

Last *

First *

M.I

Address

Street Address

Apartment/Unit #

City

State

ZIP Code

Phone Number *

E-mail Address: *

Date Available:

Social Security No.:

Desired Salary: $

Position Applied for:

Are you a citizen of the United States?

Yes

No

If no, are you authorized to work in the U.S.?

Yes

No

Have you ever worked for this company?

Yes

No

If yes, when?

Have you ever been convicted of a felony?

Yes

No

If yes, explain:

Education

High School:

Address

From

To

Did you graduate?

Yes

No

Degree

College:

Address

From

To

Did you graduate?

Yes

No

Degree

Other:

Address

From

To

Did you graduate?

Yes

No

Degree

References

Please list three professional references.

Full Name:

Relationship

Company:

Phone

Address:

Full Name:

Relationship

Company:

Phone

Address:

Full Name:

Relationship

Company:

Phone

Address:

Previous Employment

Company:

Phone

Address:

Supervisor

Job Title:

Starting Salary: $

Ending Salary: $

Responsibilities

From:

To:

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

No

Company:

Phone

Address:

Supervisor

Job Title:

Starting Salary: $

Ending Salary: $

Responsibilities

From:

To:

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

No

Company:

Phone

Address:

Supervisor

Job Title:

Starting Salary: $

Ending Salary: $

Responsibilities

From:

To:

Reason for Leaving

May we contact your previous supervisor for a reference?

Yes

No

Military Service

Branch:

From

To

Rank at Discharge:

Type of Discharge:

If other than honorable, explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. If hired, I agree to conform to the rules, regulations and policies of Belvedere Pharmacy, LLC. I understand that my employment can be terminated with or without cause and with or without notice, at anytime, at the option of either the company or myself.

I agree that any claim or lawsuit relating to my employment with Belvedere Pharmacy, LLC must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

Signature: *

Date