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:

Name

Phone Number

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?

YesNo

If yes, please indicate geographical location:

List of references

Name

Work Telephone

Home Telephone

Employer

Name

Work Telephone

Home Telephone

Employer

Name

Work Telephone

Home Telephone

Employer

Work History

Company

Supervisor

Phone Number

Address

Dates of Employment

Salary

Your Position

Reason For Leaving

Company

Supervisor

Phone Number

Address

Dates of Employment

Salary

Your Position

Reason For Leaving

Education

Name and Address of College:

Graduation Date:

Degree(s) Earned

Name and Address of College:

Graduation Date:

Degree(s) Earned

Have you been charged with or convicted of any felonies or misdemeanors that would affect your pharmacy license?
YesNo
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.
Initials
Date