EMPLOYMENT APPLICATION     
 Personal Information      * Required Fields
* How did you find us?:
      Availability Estimate
(Please Choose)
- All Days
2 - 1 day per month 3 - 2 days per month
4 - 3 - 5 days per month
5 - 1 week per month
6 - 2 weeks per month
7 - Alternating Weeks
8 - Full Time
 9 - Unknown
      Experience/Qualifications
(Please Choose all that apply)
Pharmacy Experience:









Computer/Systems Experience:

 
* Type of Application:
* Full Name:
* Address:
* City:
* State:
* Zip:
* Your e-mail Address:
* Phone:
  Mobile/Cell/Other:
   Work Phone:
   FAX:
* How would you prefer to be contacted?:
* State(s) Lic and LIC# ? :
   Date You Can Start:
* Are you a U.S. citizen?
* If NO, legally allowed?
* Ever been convicted of a felony?
* If YES, give dates/details:
Answering "yes" to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.

Summarize Any Special Skills or Qualifications:
   


APPLICANT'S STATEMENT

AUTHORIZATION, INDEMNIFICATION & HOLD HARMLESS AGREEMENT

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial and other related matters as may be necessary for an employment decision. I hereby release employers, schools or individuals from all liability when responding to inquiries in connection with my application.

In the event I contract to Pharmacy Resources Network, I understand that false or misleading information giving in my application or interviews(s) may result in discharge.

Further, as an independent contractor I agree that I shall indemnify, hold and save harmless, and defend, at my own expense, Pharmacy Resources Network, its officials, agents, employees, and clients, from and against all suits, claims, demands, and liability of any nature or kind, including their costs and expenses, arising out of acts or omissions by me, the independent contractor, including claims and liability in the nature of workmen's compensation, in the performance of my duties scheduled through Pharmacy Resources Network. I agree that the obligations under this agreement do not lapse upon termination of association with Pharmacy Resources Network. As an independent contractor I also agree to provide and thereafter maintain liability insurance in an adequate amount to cover third party claims for death or bodily injury, arising from or in connection with the provision of services contracted through Pharmacy Resources Network.


I agree to the AUTHORIZATION and INDEMNIFICATION