Please print or type. Complete all questions and sign on page 4. “SEE RESUME” is not a sufficient response to any question. Last Name First Middle Date of Application Street Address Home Telephone City, State, Zip Code Work Telephone Position Desired Date Available Salary Desired Type of Employment Desired Full Time Part Time Temporary Are you legally eligible for employment in this country? Yes No Proof of citizenship or immigration status will be required upon employment. EDUCATION Level Name and Location of School Diploma or Degree (Credits Earned if No Degree) Attendance Dates Major From Mo/Yr To Mo/Yr High School Business, Trade or Technical* College* * Other* *If degree was received under a name other than that listed on this application, please provide your full name at the time the degree was awarded: Degree: Name At Time Earned: Scholastic Achievements: SKILLS AND QUALIFICATIONS Summarize specific skills and qualifications acquired from employment or other experiences that are related to the position for which you are applying (e.g., computer skills, software applications, and foreign languages): EMPLOYMENT FOR
history, and criminal record. In the event that I am employed by Phamatech, Inc., I hereby authorize Phamatech, Inc. to answer any inquires regarding my employment, conduct, qualifications, and reasons for leaving. I understand that I have the right to request Phamatech, Inc. to disclose to me, completely and accurately, the nature and scope of the investigation. (Such a request must be made in writing to the human resources department within a reasonable time after you have completed and signed this authorization.) In exchange for being considered for employment, I hereby release Phamatech, Inc., its employees, and agents, as well as any law enforcement agency, current or former employer, educational institution, credit agency, or any other individual providing information about me to Phamatech, Inc., from any liability arising from disclosure of such information that is obtained during said investigation. Signature of Applicant Date Phamatech, Inc. is required by federal law to maintain certain information pertaining to applicants for employment. Phamatech, Inc. provides equal employment opportunity to all qualified applicants and employees by prohibiting discrimination against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, marital status, national origin, age, veteran status or disability. This information is voluntary and for record-keeping purposes only and will not affect any employment decisions. Please mark the appropriate box: Male Female I choose not to disclose More specific information is required for filing EEO-1 reports. Please check the appropriate Equal Opportunity Identification Group. You should only check one of the following ethnicity or race categories. EEO Group Status: White (Non-Hispanic) Black or African American (Non-Hispanic) Asian Hispanic/Latino American Indian or Alaskan Native Other Native Hawaiian or Pacific Islander I choose not to disclose If you would like to identify as two or more races, please check Two or More Races below, in addition to your one selection above.