Application

Pharmacy Care Associates, LLC

Application for Employment

***Drug Test & Background Check Required Before Hire***

Pharmacy Care Associates is an equal employment opportunity employer. Pharmacy Care Associates does not discriminate against applicants or employees b/c of their age, race, color, religion, national origin, sex (except where sex is a bona fide occupational qualification), disability or on any other basis prohibited by law but not limited to disabled veteran and/or veteran of the Vietnam era.

Name:

Current Address:

Are you 18 years or older?
YesNoIf not, state your DOB:

Position Applied For:
Full TimePart-TimeSummerTemporaryOther

Will You Relocate?
YesNo

Will You Travel?
YesNo

Have you ever worked for PCA?
YesNoIf Yes, when and where?

Have you ever applied to PCA?
YesNoIf Yes, when and where?

Are you legally authorized to work in this country?
YesNo

To comply with the Immigration Reform and Control Act of 1986, if you are hired you will be required to provide documents to establish your identity and your authorization to be employed in the US. Such documents will be required within the first three business days following your hire, or upon you first work day if your employment period will be less than three days.
Has the US Dept. of Health & Human Services ever excluded you as a provider of Medicaid or Medicare services?
YesNo
Have you ever been convicted of a crime (misdemeanor or felony)?
YesNo
If yes, explain:

(Disclosure of a criminal record will not necessarily disqualify you for employment). Each conviction will be evaluated on its merits with respect to time, circumstances and seriousness, in relation to the job for which you are applying:
EXPERIENCE
(MOST RECENT EXPERIENCE FIRST)
1

May we contact this employer?
YesNo
2

May we contact this employer?
YesNo
3

May we contact this employer?
YesNo
Use this space to describe any previous work history and/or to detail particular job responsibilities listed above include any additional information which you feel may be relevant to the job for which you are applying:
Please list 3 references we may contact.
1

2

3

Record of Education
High School

Graduated?
YesNo
College

Graduated?
YesNo
Grad School

Graduated?
YesNo
Other

Graduated?
YesNo
PLEASE LIST ANY PROFESSIONAL AFFILIATIONS OR ACCREDITATIONS, WHICH HAS A DIRECT BEARING UPON YOUR QUALIFICATIONS FOR THE JOB, WHICH YOU ARE SEEKING. (INDICATE ALL LICENSE AND CERTIFICATIONS, WHICH MAY RELATE TO THE JOB FOR WHICH YOU ARE APPLYING FOR).

DO YOU POSSESS A VALID CURRENT DRIVER’S LICENSE (ONLY FOR JOBS WHERE REQUIRING DRIVING A VEHICLE IS AN ESSENTIAL FUNCTION)?
YesNo

Are you currently excluded or are you aware of any potential exclusion from participation in any federally-funded healthcare program, including Medicare and Medicaid?
YesNo
Pharmacy Technician licenses are required by law. Please state your Pharmacy Technician license number here:

Please state the position you are applying for:

THE APPLICATION SHALL ONLY REMAIN ACTIVE FOR 60 DAYS. AFTER 60 DAYS, IF YOU ARE STILL INTERESTED IN EMPLOYMENT AT PHARMACY CARE ASSOCIATES, YOU MUST FILL OUT A NEW APPLICATION:
I hereby certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand and agree that any misrepresentation or omission of facts in my application my be justification for refusal to hire, or termination of employment.
I give the Employer the right to investigate all references, to contact all prior employers and to secure additional information about me if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.
I understand that as an applicant for a position with Pharmacy Care Associates, I will be applying for a position at any and all facilities operated by Pharmacy Care Associates. I understand that all Pharmacy Care Associates are a multi-functional health care employer with each location being part of a highly integrated overall operation. I understand that as an employee of Pharmacy Care Associates, I may be called upon to transfer on a temporary basis from facility to facility, as workload requires.
I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Pharmacy Care Associates and me for either employment or for the providing of any benefit. If I am offered and accept employment, I understand that the employment if for no definite period of time and may, regardless of the date and payment of my wages and/or salary be terminated under the provisions of Company policy. I understand that if I am employed by Pharmacy Care Associates, I will be employed as an employee at will.
I understand that I must meet all the physical standards established by Pharmacy Care Associates to perform the essential functions of any job for which I am offered employment, I might be required as a condition of employment to take a physical examination. I also understand that during employment I might from time to time be subjected to physical examinations and/or physical ability tests to demonstrate that I can perform functions of my job.
I understand that Pharmacy Care Associates requires that I take a drug and/or alcohol test as a condition of employment. Pharmacy Care Associates reserves the right to conduct searches on company property of employees and their personal property for alcohol, drugs, or for property which might belong to Pharmacy Care Associates. Pharmacy Care Associates also reserves the right to conduct searches of the company’s property, vehicles and/or equipment at anytime. A refusal to submit to a company search can subject an employee to employment termination.
In signing this form, I certify that I understand all the questions and statements in this application.