Corporate Employment Eligibility Verification

PERSONAL INFORMATION

Name

Current Address

City

State

Zipcode

Primary Phone

Alternate Phone

Have You Ever Been Employed By PRS?

Yes No

If Yes, When

Position You Are Applying For

Date Available For Work

CURRENT (OR MOST RECENT) EMPLOYER

May We Contact Your Current Or Most Recent Employer?

Yes No

Employer Name

Name/Title of Supervisor

Phone

Employer Address

Employer City

Employer State

Employer Zipcode

Employment Dates

Work Status

Position Held

Reason For Leaving

STATE LICENSURE

Please List All Relevant License Numbers and Corresponding States

EMPLOYMENT ELIGIBILITY

Are you authorized to work in the United States?

Yes No

Are you subject to a non-compete agreement, even if it may not be related to the position you are applying for?

Yes No

Can you, with or without reasonable accommodation, perform the specific job functions of the position for which you are applying?

Yes No

Are you currently excluded or aware of any potential exclusion from a federally funded healthcare program, including Medicare and Medicaid?

Yes No

UPLOAD RESUME

Upload your resume to help expedite the application process. This is a required action as part of your submission.

Accepted file types: PDF, DOC, DOCX
Max file size is 10MB

I CERTIFTY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I UNDERSTAND THAT UNREQUESTED INFORMATION, FALSIFICATION, MISREPRESENTATION OR OMISSION OF FACTS ON THIS APPLICATION (OR ANY OTHER ACCOMPANYING OR REQUIRED DOCUMENTS) MAY BE CAUSE FOR DENIAL OF EMPLOYMENT OR IMMEDIATE TERMINATION OF EMPLOYMENT, REGARDLESS OF WHEN OR HOW DISCOVERED.

Initials (Signature)

Full Legal Name

Date

PRS Pharmacy Services provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, marital status, national origin, age, disability, pregnancy, genetic information, veteran status or any other status protected by law.

By proceeding, you expressly consent to receive marketing communications from PRS Pharmacy Services regarding Pharmacy Compliance, Ownership, and Education matters. This includes emails and calls to the email address and phone number provided, even if you are on a corporate, state, or national Do Not Call list. You understand that these communications are not a condition of purchase, and message frequency may vary.

You also agree to our Terms & Conditions and our Privacy Policy regarding the information relating to you. Message and data rates may apply.

Corporate Employment Eligibility Verification

Apply Now at PRS Pharmacy Services

PERSONAL INFORMATION

CURRENT (OR MOST RECENT) EMPLOYER

STATE LICENSURE

EMPLOYMENT ELIGIBILITY

UPLOAD RESUME

Compliance

Buying a Pharmacy

Opening a Pharmacy

Selling a Pharmacy

Staffing

Consulting

Company