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Notice: A pre-employment drug test and an employment physical may be required for certain positions such as sales or management. Prospective employees will receive consideration without discrimination because of race, creed, color, sex, age, national origin, handicap, or religion.
  General Information
First Name
Last Name
Middle Name
Position Number
Hint:  If you are applying for a specific job, locate the position number near the bottom of the Job Posting Information Bulletin of the position you wish to apply for; otherwise, leave blank.
Social Security #
Phone
Apartment No.
Street Address
City
State
Zip/Postal Code
Age if under 18
Email Address
 
  Background Information
1 Have you ever been known by any other names which this firm will require to verify any of the information in this application?  Yes No
2 Who or what prompted you to apply for work here?
3 Are you legally eligible for employment in the United States?  Yes No
4 Have you ever been convicted of a felony or crime involving a fraudulent or dishonest act?  Yes No
5 Income expected: 
  Note: Questions 6, 7, & 8 to be completed by sales representative applicants.
6 Do you have a valid drivers license? Yes  No
7 Has your license ever been suspended/revoked? Yes  No
  8 Please list all traffic violations during the past five years:
  Employment Experience (Including Military Experience)
Please give accurate, complete full-time and part-time employment record.  Start with your present or most recent employer.
1 Date:  From To
Employer's Name: 
Employer's Address: 
Supervisor: 
Description of Duties:

Rate of Pay/Salary: 
Reason for Leaving: 
2 Date:  From To
Employer's Name: 
Employer's Address: 
Supervisor: 
Description of Duties:

Rate of Pay/Salary: 
Reason for Leaving: 
3 Date:  From To
Employer's Name: 
Employer's Address: 
Supervisor: 
Description of Duties:

Rate of Pay/Salary: 
Reason for Leaving: 
4 Date:  From To
Employer's Name: 
Employer's Address: 
Supervisor: 
Description of Duties:

Rate of Pay/Salary: 
Reason for Leaving: 
5 Date:  From To
Employer's Name: 
Employer's Address: 
Supervisor: 
Description of Duties:

Rate of Pay/Salary: 
Reason for Leaving: 
  May we contact the employers listed above?  Yes No
If not, indicate which one(s) you do not wish us to contact:
  If you have been unemployed at any time since leaving school, please state what you were doing during this time:
  Personal References (Not former Employers or Relatives)
1 Name: 
Occupation: 
Address: 
Phone No.: 
2 Name: 
Occupation: 
Address: 
Phone No.: 
3 Name: 
Occupation: 
Address: 
Phone No.: 
  Education
High School Name of School: 
Address of School: 
Advisor/Counselor: 
Highest Year Completed:  9  10  11  12  GED
Technical, Trade, or Business College Name of School: 
Address of School: 
Advisor/Counselor: 
Number of Months Attended: 
Subject Studied: 
College Name of School: 
Address of School: 
Advisor/Counselor: 
Highest Year Completed:  1  2  3  4
Degree Received: 
Other (Specify) Name of School: 
Address of School: 
Advisor/Counselor: 
Amount of Education Completed: 
Subject Studied: 
  Skills
State the approximate number of months or years you have had practical experience with any of the following:
Accounting/Bookkeeping:  10-Key/Calculator:  
Business Telephone:  Receptionist: 
Insurance Experience*:   Sales Experience: 
Personal Computers:  List any other skills:  
*Type of Insurance Experience (Explain): 
  Objective
Please write a brief statement in which you express the kind of work you desire, and your career interests:
  PLEASE READ CAREFULLY:
It is agreed and understood that if hired by The Pharmacists Mutual Companies my employment will be "at will."   I will be free to terminate my employment at any time and for any reason.   Similarly, the company may terminate my employment (and compensation) at any time and for any reason.  My employment will not create any contractual rights or obligations.

If I am granted employment, I agree to conform to the rules and regulations of The Pharmacists Mutual Companies.

I authorize you to obtain an investigative consumer report containing information obtained through personal interviews with my neighbors, friends, and acquaintances.  This report, if obtained, may include information as to my character, general reputation, personal characteristics and mode of living.  I understand I have the right to make a written request within a reasonable period to receive additional detailed information about the nature and scope of any such investigation.

I hereby affirm that I have read the instructions and the foregoing questions and that my answers to them are true and correct, and that I have not knowingly withheld any fact or circumstance that could, if disclosed, affect my application unfavorably.

Note: The next paragraph applies to sales representative applicants only.

I agree and give my permission for Pharmacists Mutual Insurance Company to obtain personal motor vehicle reports pertaining to my driving record.

Any misrepresentation, when discovered, will result in termination.

Signature: 
Represent your signature by typing your full name into the box above.