PERSONAL INFORMATION

            Name:   Date: 
            Email:   SSN:  
            Phone:   Cell Phone: 
            Street Address:  
            City: State:  Zip:
            Drivers License #:   State:
            What position are you applying for?  
            Are you legally entitled to work in the US?   Are you over 18 years old? 
            Have you ever been charged with a felony? 
            If yes, what was the charge? 
            Have you ever been addicted to legal or illegal drugs? 
            If yes, please explain below:
            
            Do you have any physical or psychological conditions that could impact
            your job performance?  
            If yes, please explain below:
            

            EDUCATION

            High School:
            Name: 
            City & State or Country: 
            Number of years attended: 
            Did you graduate? 
                    
            Trade School:
            Name: 
            City & State or Country: 
            Number of years attended: 
            Did you graduate? 

            College:
            Name: 
            City & State or Country: 
            Number of years attended: 
            Degree: 

            Post Graduate::
            Name: 
            City & State or Country: 
            Number of years attended: 
            Degree: 

            Professional License(s):   State:
            Expiration Date: 

            EMPLOYMENT HISTORY

            Current Employer: 
            Job Title: 
            Street Address: 
            City & State & Zip: 
            Supervisor:   Phone:   Ext: 
            Dates of Employment:  From    To 
            Rate of Pay:  Per  
            Reason for Leaving:
            

            Employer:   Job Title: 
            Street Address: 
            City & State & Zip: 
            Supervisor:   Phone:   Ext: 
            Dates of Employment:  From    To 
            Rate of Pay:  Per  
            Reason for Leaving:
            

            Employer:   Job Title: 
            Street Address: 
            City & State & Zip: 
            Supervisor:   Phone:   Ext: 
            Dates of Employment:  From    To 
            Rate of Pay:  Per  
            Reason for Leaving:
            

            Employer:   Job Title: 
            Street Address: 
            City & State & Zip: 
            Supervisor:   Phone:   Ext: 
            Dates of Employment:  From    To 
            Rate of Pay:  Per  
            Reason for Leaving:
            

            REFERENCES

            Name: 
            Phone: 
            Relationship:  

            Name: 
            Phone: 
            Relationship:  

            Name: 
            Phone: 
            Relationship:  

            Name: 
            Phone: 
            Relationship:  



            Please tell us about any other training, education, skills, or achievements that you feel
            should be considered:
            

            AUTHORIZATION TO RELEASE INFORMATION

            By sending in this application I authorize CHS Pharmacy permission to gather the following
            information:

            I authorize CHS Pharmacy permission to obtain information about me from my previous employers,
            schools, and credit sources.

            I authorize my previous employers and/or schools that I have attended and credit sources
            to disclose such information about me as CHS Pharmacy may request.

            I authorize my previous employers to candidly disclose to CHS Pharmacy all facts and opinions
            concerning my work performance, cooperativeness and ability to get along with others.

            I authorize CHS Pharmacy to require and obtain a criminal history report.

            I authorize CHS Pharmacy to require and obtain reports of a drug screening test.

            The information I have provided is true and complete.  I understand that if I am hired,
            any false or incomplete statements in this application will be grounds for immediate termination.

            
            Thank You For Your Application!