Position Applying For:
RECORD OF EMPLOYMENT
Describe specialized training, certifications, skills, licenses, and activities that are pertinent for the
position that you are applying for. (You may exclude organizations and activities that indicate race,
religion, sex or national origin).
State any additional experience you feel may be helpful to Mallatt’s Pharmacy in considering your
WORK-RELATED REFERENCES: (Do not include relatives)
STATEMENT (Please read this statement carefully before submitting this application):
I certify that the information given on this Application is true and complete. I understand that any misstatements or omissions of information are grounds for denial of employment and, if hired, for dismissal. I understand that employment is conditioned upon verification of the information obtained herein, as well as my passing a pre-employment drug test.
I give Mike Flint Enterprises, dba Mallatt’s Pharmacy, the right to request, and I give listed employers, schools, and professional references (as well as any other persons; schools; companies; credit bureaus; state licensing law enforcement and other governmental agencies), the right to give Mallatt’s Pharmacy (without further notice to me) any and all information about my background, along with any other pertinent information that they may have, personal or otherwise. I release all parties from all liability and agree not to file any claim, lawsuit, or any other cause of action of any kind against any person or any entity arising out of the furnishing receipt or use of such information.
In consideration of my employment at Mallatt’s Pharmacy, I agree to learn and conform to Mallatt’s Pharmacy’s rules and regulations. I further agree that employment with Mallatt’s Pharmacy is at will and that either I, or the Company, may terminate my employment without notice at any time for any reason. I understand that I have no written or oral employment contract with Mallatt’s Pharmacy.
Equal Employment Opportunity Voluntary Self-Identification
Affirmative Action Employer
Mike Flint Enterprises, Inc., dba Mallatt's Pharmacy, is an Equal Opportunity Employer. As required by law, we must record information to be made a part of our Affirmative Action Program.
Applicants for employment are invited to participate in the Affirmative Action Program by reporting their race/ethnic group, status as a veteran, or individual with disabilities. In extending this invitation, you are advised that: (a) applicants are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our Affirmative Action Program. We are a company that values diversity. Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.
Attach Your Resume (optional):
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.
A person having origins in any of the black racial groups of Africa.
Native Hawaiian/Pacific Islander
A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian/Alaska Native
A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.
Two or More Races
All persons who identify with more than one of the above races.
Vietnam Era Veteran
A person who: (i) served on active duty in the U.S. military, ground, naval or air service for a period of more than 180 days, and who was discharged or released there from with other than a dishonorable discharge, if any part of such active duty was performed: (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in all other cases; or (ii) was discharged or released from active duty in the U.S. military, ground, naval or air service for a service connected disability if any part of such active duty was performed (A) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (B) between August 5, 1964, and May 7, 1975, in any other location.
Special Disabled Veteran
A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay
would be entitled to compensation) under laws administered by the Department of Veterans' Affairs for a disability (A) rated at 30 percent or more; or (B) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 38 U.S.C. 3106 to have a serious employment handicap; or a person who was discharged or released from active duty because of a service connected disability.
Other Protected Veteran
Any veteran who served on active duty in the U.S. military, ground, navel or air service in a war, campaign or expedition in which a campaign badge has been authorized under laws administered by the Department of Defense.
Recently Separated Veteran
Any veteran who served on active duty in the U.S. military, ground, naval or air service during the one year period beginning on the date of such veteran’s discharge or release from active duty.
Armed Forces Service Medal Veteran
Any veteran who, while serving on active duty in the Armed Forces, participated in a United States military operation for which a service medal was awarded pursuant to Executive Order 12985.
Individual with Disabilities
A person who (1) has a physical or mental impairment which substantially limits one or more of his or her major life activity(s); (2) has a record of such impairment(s); or (3) is regarded as having such impairment(s). For purposes of this definition, an individual with disability(s) is substantially limited if he or she is likely to experience difficulty in securing, retaining, or advancing in employment because of the disability(s).