Careers

Main Street Pharmacy (MSP) is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability. We assure you that your opportunity of employment with MSP depends solely on your qualifications.
Today's Date*

MM slash DD slash YYYY
Positions
- Pharmacist
- Pharmacy Technician
- Compounding Technician
- Delivery Specialist
- DME Specialist
- PGY1 Pharmacy Resident

PERSONAL DATA (Please Print)
Name*
Last First M.I
Social Security Number*
(FOR USE IN VERIFICATION OF EMPLOYMENT REFERENCES)
Address*
City*
State*
Zip Code*
Home Telephone*
Cell/Business Phone*
Email Address*

EMERGENCY CONTACT
Name*
Address*
Phone Number*
Are you under 18 years of age:*
- Yes
- No
Driver's License Number/ID Number*
State*
Have you ever been employed by Main Street Pharmacy(MSP) before?*
- Yes
- No
If YES, Please indicate:
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
List names of friends or relatives, if any, employed by MSP (Give relation of all)
Position applied for*
Date you are available to begin work*
MM slash DD slash YYYY
Days you are available to work*
Hours you are available to work*
*As a condition of employment with MSP, you must provide proof of eligibility to work in the United States, pursuant to Federal Immigration Law.

PHYSICAL DATA
Do you have the ability to perform each of the specific functions of the job being sought?*
- Yes
- No
If No, explain fully and state what you feel MSP could reasonably do to enable you to perform the functions of the job.*

MILITARY DATA
Have you ever been in the military?*
- Yes
- No
If YES, please indicate branch, service dates and final rank*

SECURITY DATA
Have you ever been convicted?*
- Yes
- No
If YES, state offense and date convicted. (OMIT Minor traffic violations)*
Have you ever been bonded?*
- Yes
- No
If YES, give name of employer and date*

EDUCATION DATA
School or Training
NAME AND LOCATION*
YEARS COMPLETED*
COURSE OF STUDY*
DIPLOMA/ DEGREE EARNED*
High School or Last Grade Completed
NAME AND LOCATION*
YEARS COMPLETED*
COURSE OF STUDY*
DIPLOMA/ DEGREE EARNED*
College
NAME AND LOCATION*
YEARS COMPLETED*
COURSE OF STUDY*
DIPLOMA/ DEGREE EARNED*
Business, Technical Trade or Vocational
NAME AND LOCATION*
YEARS COMPLETED*
COURSE OF STUDY*
DIPLOMA/ DEGREE EARNED*
Other: Post Graduate, Special Military Training, Other Special Courses
NAME AND LOCATION*
YEARS COMPLETED*
COURSE OF STUDY*
DIPLOMA/ DEGREE EARNED*
PROFESSIONAL/TECHNICAL CERTIFICATION
Professional or Technical Specialty*
License #*
Present License:
Issue Date*
MM slash DD slash YYYY
State*
Current Expiration Date*
MM slash DD slash YYYY
Connecticut License Applied for?:*
- Yes
- No
Original Date of Licensure*
MM slash DD slash YYYY
Have you ever had professional or technical license revoked?*
- Yes
- No
If YES, Please explain*
SPECIAL TRAINING OR SKILLS
List any office, mechanical or medical training or certifications, and any office machines or equipment you can operate including personal computer types and programs:*

EMPLOYMENT HISTORY
List all jobs and activities including military service, schools, part time employment while in school, self employment, and periods of unemployment for the past 10 years. Please also list significant experience more than 10 years ago. Begin with the most recent. Do NOT reference a resume. Please fill in ALL blanks.
Present or most recent:
Employer*
Phone*
Address*
Name and title of supervisor*
Position(s) held*
Hours worked per week*
Duties performed*
Date employed*
MM slash DD slash YYYY
Date separated*
MM slash DD slash YYYY
Ending salary*
Past Employers
Employer

Phone
Address

Name and title of supervisor

Position(s) held

Hours worked per week

Duties performed
Date employed
MM slash DD slash YYYY

Date separated
MM slash DD slash YYYY

Ending salary

May we contact this employer?

Yes

No

REFERENCES
List THREE people that are NOT relatives or former employers you have known for 5 or more years.

1)
Name*
Occupation*
Address & Telephone*
Years Known*
2)
Name
Occupation
Address & Telephone
Years Known*
3)
Name
Occupation
Address & Telephone
Years Known*
AFFIDAVIT
NOTE: PLEASE READ CAREFULLY BEFORE SIGNING
I understand that if I am employed by Main Street Pharmacy, MSP, that I would be entering into a termination-at-will relationship. I understand that means that my employment is not for a stated period and that I may be terminated whenever it is in MSP's best interest. I understand that I may be terminated at any time with or without cause. I further understand that no one can make any oral statements or promises regarding job tenure or job security, which are contrary to the above written declarations of company policy regarding termination-at-will.
I authorize MSP to inquire of my former employers, all references and companies noted herein, appropriate credit bureaus, local police departments, registrars of motor vehicles and other state and state and federal bureaus and departments concerning my past employment character and to obtain a copy of my motor vehicle record. I release and discharge any party delivering information to MSP or its duly authorized representative pursuant to this authorization from any liability, claims, charges or causes of action which I might have as the result of the delivery or disclosure of such information.
I acknowledge that MSP has a “Drug-Free Workplace Policy.” I agree, as a condition of continuing employment, that I will NOT engage in the unlawful manufacture, use, possession, sale or distribution of controlled substances. I understand that violation of this policy may result in immediate termination of employment. I further agree to submit to drug testing or screening as permitted by law and required by MSP.
I certify this application was completed by me, and that all information in it is true and complete to the best of my knowledge. I understand that I will be subject to dismissal if anything in this application is found to be false in any particular.
If employed, I agree that all claims relating to my employment, other than worker's compensation claims or claims arising under a non-compete agreement, shall be settled exclusively by expedited arbitration, without discovery. There shall be one arbitrator, chosen by the American Arbitration Association (AAA) and the claim otherwise processed in accordance with AAA Rules. Any award to me shall be limited to the lesser of
1. any actual lost wages,
2. an amount not to exceed six months' wages, or
3. in an appropriate case, reinstatement. The cost of arbitration shall be shared equally between me and the company.
****Please note: You may wish to consult an attorney prior to signing this application. If so, please take this form with you. However, you will not be offered employment until it is signed without modification and returned.****
Signature*
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

PERSONAL DATA (Please Print)

EMERGENCY CONTACT

PHYSICAL DATA

MILITARY DATA

SECURITY DATA

EDUCATION DATA

School or Training

High School or Last Grade Completed

College

Business, Technical Trade or Vocational

Other: Post Graduate, Special Military Training, Other Special Courses

PROFESSIONAL/TECHNICAL CERTIFICATION

SPECIAL TRAINING OR SKILLS

EMPLOYMENT HISTORY

Present or most recent:

REFERENCES

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