Your Name (First, MI, Last) (required)
Your Address (required)
City, State, ZIP (required)
Home Phone Number (required)
Cell Phone Number (required)
Work Phone Number (required)
OK to contact at work? YesNo
Email Address (required)
State / License Number 1 (required)
State / License Number 2
State / License Number 3
Please provide the name and phone number of who we should contact in case of emergency:
Please List specific scheduling requests or requirements (ex. Number of hrs/wk):
How did you learn of S & L Solutions, LLC?:
Are you interested in relocating?
If yes, please indicate geographical location:
Dates of Employment
Reason For Leaving
Name and Address of College:
Have you been charged with or convicted of any felonies or misdemeanors that would affect your pharmacy license?
If yes, details
What accommodations (based on any mental or physical conditions), if any, would we need to provide in order for you to perform your job effectively?
By submitting this form, I hereby give permission to S & L Solutions, LLC to conduct a reference, license and criminal investigation check on myself. I am aware that no such investigation would occur before a position had been offered and accepted by myself.