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? 

                    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!