Employment Application

If you are looking for a dynamic career with a cutting edge specialty pharmacy that is aggressively growing, professional and supports an entrepreneurial spirit we want to hear from you.

Diplomat Specialty Pharmacy is the nation’s largest, independently owned specialty pharmacy.

Clinical data shows that our disease management programs are keeping patients healthier… longer.

At Diplomat, “out-of-the-box” thinking is encouraged. We constantly seek out innovative ways to better serve patients, payors, physicians and manufacturers.

We create, develop and launch new initiatives at a rapid and efficient pace.

If you are interested in joining the Diplomat Team please complete our online employment application form. Diplomat Specialty Pharmacy is an equal opportunity employer.

Note: Required fields are marked with an asterisk (*)

Personal

First Name *

Last Name *

Email Address

Social Security No. *

Address 1 *

Address 2

City *

State *

Zip *

Telephone *

(###) - ### - ####

Age I certify that I am 18 years of age or older.

(If under age 18, employment is subject to verification that you are of minimum legal age.)

Have you ever been convicted of a crime, or had an adjudication withheld, other than a minor traffic offense? Yes

If yes, please state the date, nature of offense, and other circumstances. NOTE: A conviction does not automatically mean you cannot be hired. What you were convicted of and how long ago are important. Give all of the facts so that a decision can be made.

Employment Desired

Position(s) applied for:

Position 1 , Rate of pay expected: $ Per:

Position 2 , Rate of pay expected: $ Per:

Diplomat city location you are applying to

Do you want to work Full-time? Part-Time?

Days and Times Available:

If hired, on what date will you be available to start working? mm/dd/yyyy

Are there any other experiences, skills, or qualifications which you feel would especially fit you for work with the Company?

Prior Work History (List in order, current, or most recent employer first)

Work History 1

Employer Name,
Phone & Address

Dates of Employment From: mm/yyyy To: mm/yyyy

Rate of Pay Start: $ Finish: $

Supervisor's Name

Supervisor's Title

Your Job Title

Reason for Leaving

Describe in detail the work that you did:

May we contact this employer? Yes

Work History 2

Employer Name,
Phone & Address

Dates of Employment From: mm/yyyy To: mm/yyyy

Rate of Pay Start: $ Finish: $

Supervisor's Name

Supervisor's Title

Your Job Title

Reason for Leaving

Describe in detail the work that you did:

May we contact this employer? Yes

Work History 3

Employer Name,
Phone & Address

Dates of Employment From: mm/yyyy To: mm/yyyy

Rate of Pay Start: $ Finish: $

Supervisor's Name

Supervisor's Title

Your Job Title

Reason for Leaving

Describe in detail the work that you did:

May we contact this employer? Yes

Work History 4

Employer Name,
Phone & Address

Dates of Employment From: mm/yyyy To: mm/yyyy

Rate of Pay Start: $ Finish: $

Supervisor's Name

Supervisor's Title

Your Job Title

Reason for Leaving

Describe in detail the work that you did:

May we contact this employer? Yes

Extra Information

Occasionally, the form of an application blank makes it difficult for an individual to adequately summarize his/her complete background. To assist us in finding the proper position for you in our company, use the space above to summarize any additional information in order to describe your full qualifications.

Personal References (Excluding Former Employers or Relatives)

Reference 1

Name,
Phone & Address

Reference 2

Name,
Phone & Address

Reference 3

Name,
Phone & Address

Education

Elementary

Name & Address of School

Course of Study

Year Completed 5 6 7 8

Years Attended

List Diploma or Degree

High school

Name & Address of School

Course of Study

Year Completed 9 10 11 12

Years Attended

List Diploma or Degree

College

Name & Address of School

Course of Study

Year Completed 1 2 3 4

Years Attended

List Diploma or Degree

College 2

Name & Address of School

Course of Study

Year Completed 5 6 7 8

Years Attended

List Diploma or Degree

Other education

Name & Address of School

Course of Study

Year Completed 1 2 3 4

Years Attended

List Diploma or Degree

Skills & Development

List any specialized training or skill development that apply to this position.

Note any honors and extra curricular activities that may relate.

Emergency Information

Person to be notified in case of accident or emergency.

Name

Relationship to Applicant

Address 1

Address 2

City

State

Zip

Telephone

(###) - ### - ####

Immigration Reform and Control Act of 1986

I understand that, if hired, I will be required to offer for examination documents proving that I am a United States citizen or an alien currently authorized to work in the United States. I also understand that my continued employment is contingent upon my providing the necessary documentation within the prescribed time frames.

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE.

Applicant's Certification and Agreement

I authorize an investigation of my personal or employment history, and of all statements contained in this application. I authorize any former employer, person, firm, corporation, credit agency to report any information they may have regarding me, and I release all providers of information from any liability as a result of furnishing this information. I understand that any misrepresentation or omissions in this application shall be considered cause for disqualification from further consideration for hire or for dismissal if discovered subsequent to being hired.

I agree to confirm to the rules and regulations of the Company and understand and agree that, if hired, my employment is for no definite periods and may, regardless of my designated pay period or salary, be terminated at any time, for any reason, without any previous notice, at either my or the company's option. I also understand and agree that no employee of the Company, other than the President, has any authority to enter into any agreement for employment for a specified period, or to make any agreement or representation contrary to the provisions of this Application and Agreement.

I agree

* Thank you for completing this application form and for your interest in employment with us. We would like to assure you that your opportunity with this company will be based only on your merit and on no other consideration.

Diplomat Pharmacy

Keeping patients healthier... longer™

Employment Application