Pharmacist (PM Shift)

Personal Information

Full Name *

Address *

City, State, ZIP *

Phone Number *

Email Address *

Preferred Contact Method *

Phone

Email

Position Details

Position Applying For: *

Available Start Date *

Willing to work across multiple locations? *

Licensure & Certification

State of Ohio Pharmacist License Number: *

License Status *

Expiration Date

DEA Registration Number *

DEA Registration Status *

NPI Number (if applicable)

Immunization Certification *

MTM (Medication Therapy Management) Certified *

CPR/BLS Certification *

CPR/BLS Certification Expiration Date (If Applicable):

Are you authorized to work in the U.S.? *

Education

School/Institution *

Degree *

Year Completed *

Residency or Fellowship Training *

PGY-1

PGY-2

Fellowship

None

If applicable, specify area of specialization:

References

Provide two professional references:

Name *

Relationship *

Phone/Email *

Name *

Relationship *

Phone/Email *

Briefly describe your motivation for joining University Urgent Care & Pharmacy and how your experience aligns with our mission of patient-centered care. *

Personal Statement

Briefly describe your motivation for joining University Urgent Care & Pharmacy and how your experience aligns with our mission of patient-centered care.

Applicant Certification

By submitting this application, I affirm that all information provided is true and complete to the best of my knowledge. I understand that any misrepresentation or omission may result in denial or termination of employment.

Signature (Typed) *

Date *

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