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Employment

Grove Park Pharmacy is currently seeking a Certified Pharmacy Technician to join our team.

We are also seeking an Assistive Technology Professional (ATP) to work with our wheelchair bound patients.

Applicant Information

Full Name: *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *
Email *
Date of Birth *
Department
Date Available
Desired Salary
Are you a citizen of the United States?
YesNo
If no, are you authorized to work in the U.S.?
YesNo
Have you ever worked for this company before?
YesNo
If yes, when?
Have you ever been convicted of a felony?
YesNo
If yes, please explain.

Education

High School

Date Started

Date Completed

Did you graduate?

YesNo

Degree obtained?

College

Date Started

Date Completed

Did you graduate?

YesNo

Degree obtained?

Other

Date Started

Date Completed

Did you graduate?

YesNo

Degree obtained?

Previous Employment

Company Name
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Date Started
Date Ended
Reason for leaving
May we contact your supervisor for a reference?
YesNo

Company Name
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Date Started
Date Ended
Reason for leaving
May we contact your supervisor for a reference?
YesNo

Company Name
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Date Started
Date Ended
Reason for leaving
May we contact your supervisor for a reference?
YesNo

References

Please list three professional references

1. Name

Company

Relationship

Phone

Address

2. Name

Company

Relationship

Phone

Address

3. Name

Company

Relationship

Phone

Address

Military Service

Branch
Date Started
Date Ended
Rank at Discharge
Type of Discharge
If other than honorable, please explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this applicant leads to employment, I understand that false or misleading information in my application and/or interview may result in my release.

Please upload resume if availiable.

E-Signature *

Date *

Verification

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1324 Grove Park NE Orangeburg, SC 29115
(803) 536-0007

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