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PAMIDA EMPLOYMENT APPLICATION
TO THE APPLICANT: We appreciate your interest in our company. The information requested in this form will give us a clear understanding of your qualifications, background, and work history, and will aid us in placing you in a position for which you are thereby best suited. The Civil Rights Act of 1964, as amended, prohibits discrimination in employment because of race, color, sex, religion, or national origin. The Age Discrimination in employment Act of 1967, as amended, prohibits discrimination because of age. The Americans with Disability Act prohibits discrimination against those with disabilities. Various state laws prohibit some of the above as well as other types of discrimination. As an Equal Opportunity Employer, our company intends to comply fully with all applicable federal and state employment laws.
POSITION INFORMATION
POSITION YOU ARE APPLYING FOR:
Store Support (Corporate)  
Store Leadership  
General Store Postion
Pharmacy  
PERSONAL DATA
FULL NAME:
  
First Name:
 M.I.:
 Last Name:
 
PRESENT ADDRESS:
PHONE NUMBERS:
Street Address:
City:
 State:
 Zip:
Email:
Home Phone:
Alternate / Cell Phone:
Are you UNDER 18 years of age? Yes No
Are you UNDER 16 years of age? Yes No
Have you been convicted of a crime within the last 7 years? Yes No
If yes, explain fully:
JOB INTEREST:
Position Desired:
 Desired Salary:
 Date Available?:
full time part time other Have you ever been employed by Pamida?: Yes No

If yes, when and where?:
EDUCATION
TYPE
NAME
LOCATION
(Complete mailing address)
DEGREE
MAJOR
High School Graduated? Yes No
College
Graduate School
Other Schools
(vocational, military, etc)
List any extracurricular interests, additional skills, licenses or professional certifications which you feel may qualify you for the position for which you are applying:

PROFESSIONAL LICENSE
(APPLICABLE TO PHARMACY ONLY)
STATES REGISTERED
REGISTRATION NUMBERS
STATE NARCOTIC NUMBERS
1) 1) 1)
2) 2) 2)
3) 3) 3)
Have you ever been excluded from participating as a provider of services in federal programs such as Medicare or Medicade? Yes No
If yes, explain fully:
Have you ever had your professional license suspended or revoked? Yes No
If yes, explain fully:
EMPLOYMENT HISTORY
(COMPLETE THIS SECTION IN ADDITION TO ANY RESUME YOU SUBMIT)
PRESENT OR MOST RECENT EMPLOYER:
SUPERVISOR:
Name of Company:
 Type of Business:
Street Address:
City:
 State:
 Zip:
Supervisor Full Name:
Supervisor Title:
Supervisor Phone #:
EMPLOYMENT DATES (Month and Year):
Start Date:
 End Date:
JOB INFORMATION:
Position Title:
 Brief description of position:
Starting Salary:
 Final Salary:
 Reason for Leaving:
May we contact this employer?: Yes No

FIRST PREVIOUS EMPLOYER:
SUPERVISOR:
Name of Company:
 Type of Business:
Street Address:
City:
 State:
 Zip:
Supervisor Full Name:
Supervisor Title:
Supervisor Phone #:
EMPLOYMENT DATES (Month and Year):
Start Date:
 End Date:
JOB INFORMATION:
Position Title:
 Brief description of position:
Starting Salary:
 Final Salary:
 Reason for Leaving:
May we contact this employer?: Yes No

SECOND PREVIOUS EMPLOYER:
SUPERVISOR:
Name of Company:
 Type of Business:
Street Address:
City:
 State:
 Zip:
Supervisor Full Name:
Supervisor Title:
Supervisor Phone #:
EMPLOYMENT DATES (Month and Year):
Start Date:
 End Date:
JOB INFORMATION:
Position Title:
 Brief description of position:
Starting Salary:
 Final Salary:
 Reason for Leaving:
May we contact this employer?: Yes No
RESUME
ACCURACY AND CONFIRMATION

PLEASE READ CAREFULLY:

I certify that the information contained in this application is true and complete to the best of my knowledge. I understand that false or misleading facts or omission of information or any other information associated with my application for employment is grounds for refusal to hire, rejection of the application or, if hired, dismissal of employment.

I authorize any of the persons or organizations referred to in this application to give you any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release all such parties from all liability for any damage that may result from furnishing such information to you. I authorize you to request and receive such information, and I will indemnify you against any liability that may result from making such investigation.

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between this Company and myself for either employment or for providing of any benefit. I also understand that if hired, my employment is to be "at will" and that either I or the Company may terminate my employment at any time, with or without cause.

I acknowledge that it is the Company's policy to hire only authorized workers and any offer of employment to me by this Company is contingent upon my timely completing INS Form I-9 and producing the proper documents required by the Immigration Reform and Control Act of 1986 and may not be amended. My failure to meet these requirements within the specified time limit will result in the termination of my employment.


The following must be completed for this application to be processed.
  • I certify that the information contained in this application is true and complete to the best of my knowledge.
    YES NO
  • Please enter your full legal name.


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