I request to be considered for a Pharmacist position at the following store or stores. I understand that when an opening in the specified areas occurs I will be contacted and considered for the position.



Pharmacist's Name: __________________________________________________




Pharmacist's Signature: _____________________________________________




_____ Store preferences (list as many as apply): ______________________________________

_____________________________________________________________________________.




_____ Geographic Preference: ____________________________________________________.




_____ Any Single Store (in specified geographic area): _________________________________.




Date Form Submitted: ___________________________________________________________.




Name of Person to whom Form Submitted: __________________________________________.





Pharmacists - please retain a copy for your records.