BASIC INFORMATION:

First Name: *                 Middle Initial:

Last Name: *

Address: *

City: *           State: *         Zip: *

Home Phone: * (i.e. 1234567890)

Email Address: *

Are you currently authorized to work in the United States?    yes    no

Do you or will you in the future require sponsorship for a work visa?    yes    no
(Note: All applicants hired by Ahold USA will be required to present documentation that verifies identity and authorization to work in the United States in accordance with the Immigration Reform and Control Act of 1986.)

Are you under 18 years of age?    yes    no

If yes, can you furnish a work permit if required?    yes    no

Were you ever employed by any other company owned by Ahold USA?    yes    no

If yes, date(s) employed:

Locations:

Have you ever filed an application for employment at this company before?    yes    no

If yes, date:

Do you have friends/relatives employed by this company?    yes    no

If yes, please indicate names/locations:

How did you learn of this opportunity?    Advertisement    TV    Radio    Company Associate         

Internet    Job Fair    In-store Sign    Other

When can you start? (date)

Type of employment desired:    Full Time     Part Time      Temporary  *

Hours available: Any Time/Any Day  *

Do you have a high school diploma or equivalent?    yes    no

Highest Grade Completed:

High School Name:

City/State:

Additional Education 1:    City/State:  Degree/Major:

Additional Education 2:    City/State:  Degree/Major:

Additional Education 3:    City/State:  Degree/Major:

Please begin with most recent employer. Give all information requested below, even if duplicated on your resume. If your earnings on previous jobs were on a commission or other basis, estimate them on a weekly basis. You may include any verified work performed on a volunteer basis.

Previous Employer 1:   

Company Name:     Telephone Number: (1234567890)

Address:    Position Held:

Employed From: To           Last Wage:

Supervisor's Name:        Reason for Leaving:

Previous Employer 2:   

Company Name:     Telephone Number: (1234567890)

Address:    Position Held:

Employed From: To           Last Wage:

Supervisor's Name:        Reason for Leaving:

Previous Employer 3:   

Company Name:     Telephone Number: (1234567890)

Address:    Position Held:

Employed From: To           Last Wage:

Supervisor's Name:        Reason for Leaving:

Are you a registered Pharmacist?    yes    no

If so, list states and license numbers:

1.

2.

3.

Have you ever appeared before any pharmacy board for violation of any pharmacy codes?    yes    no

Have you, or any pharmacy that you have been associated with, ever been sanctioned by a State Medicaid, Federal Medicare Program, or any other government Agency?    yes    no

If yes, please explain:

Have all required continuing education credits been fulfilled?    yes    no

Has any state licensing or pharmacy board ever conducted an investigation into your practice? yes    no

If yes, please explain:

Has any state licensing or pharmacy board ever denied, restricted, suspended, terminated or imposed probation, reprimand of any other terms and conditions on your license to practice pharmacy? yes    no

If yes, please explain:

Please provide the names of three persons not related to you whom we may contact for work references. Ahold USA reserves the right to contact other individuals for references as well.

Reference 1:     Telephone Number: (1234567890)

Association:     Years Known:

Reference 2:     Telephone Number: (1234567890)

Association:     Years Known:

Reference 3:     Telephone Number: (1234567890)

Association:     Years Known:

Please answer the following questions.
Note: In Connecticut, you are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a. The criminal records subject to erasure pursuant to these statutes are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon. In addition, any person whose criminal records have been erased pursuant to these statutes shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath.

Note: You may answer “No” if any of the following circumstances are applicable:
1. You have a first conviction for any of the following misdemeanors: drunkenness, simple assault, speeding, minor traffic violations, affray, or disturbance of the peace; or, in Pennsylvania, you have been convicted of a summary offense.
2. You have felony or misdemeanor convictions which have been annulled, expunged, or sealed by a court.
3. You have juvenile delinquency or child in need of service complaints which were not transferred to Superior Court for prosecution or which were expunged.

Answering “Yes” will not automatically result in disqualification.

1. Have you ever been convicted of a felony?    yes    no

If yes, list all and explain:

2. Have you been convicted of a criminal offense within the last five (5) years?    yes    no

If yes, list all and explain:

3. Have you been convicted of a criminal offense for which your period of incarceration ended within the past five (5) years?    yes    no        If yes, list all and explain:

Falsification of any portion of this application will result in disqualification and/or termination if hired.

Please initial:

If offer of employment is conditional upon the results of a drug screening test, are you willing to take one?    yes    no

If offer of employment is conditional upon the results of a post-offer physical and/or a functional job capacity test, are you willing to take one?    yes    no

Have you ever been refused an employment bond?    yes    no

Have you ever held a job before?    yes    no

Have you ever been discharged or asked to resign by an employer?    yes    no

If yes, please explain:

Those applicants seeking employment in the State of Maryland must respond to the following statement:
Maryland Polygraph Statement:

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

I acknowledge receipt of the Maryland Polygraph statement:    yes    no

Massachusetts Polygraph Statement: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Employment Application Statement:

I certify that the statements made on this application are true and complete and I further agree that such statements may be investigated to verify accuracy. I further understand that any misleading or incorrect information, misrepresentation, or omission of facts may render this application void or may be cause for immediate dismissal whenever discovered.

I understand that any offer of employment may be conditional on the results of a physical examination and/or functional job capacity test and/or drug and/or alcohol screening test by a physician and/or laboratory designated by Ahold USA. Furthermore, any job offer also will be contingent upon satisfactory references. In accordance with applicable state and federal laws, Ahold USA reserves the right to engage outside services to conduct background checks on applicants for employment. This statement has been included in my application for employment to inform me in this regard. I acknowledge that I have been advised that I have a right to request in writing information concerning the nature and scope of any such investigation. I agree to cooperate in such an investigation and I hereby release from liability all persons, firms, schools, organizations and/or corporations furnishing references or other information concerning me. I also release Ahold USA, its affiliated companies, associates, and agents from any liability which might result from requesting such information.

The acceptance of this application does not necessarily indicate that there are positions open at present. I also recognize that Ahold USA policies, rules, benefit plans, and procedures may be modified or amended at any time at the discretion of Ahold USA.

If employed, I agree to conform to the rules and regulations of Ahold USA and understand that my employment and compensation can be terminated with or without cause at any time at the option of Ahold USA or myself. I understand that no representative of Ahold USA other than the authorized officers have any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing. Any such agreement made by an authorized officer must be in writing.

I further understand that if and while I am employed in a position covered by a collective bargaining agreement between Ahold USA and a collective bargaining representative, the terms and conditions of my employment shall be subject to such collective bargaining agreement to the extent they differ from any provisions of this application.

I acknowledge that I have read and understood all of the provisions of this application:    yes    no

If you would like to attach your resume, please attach it to this form:

(Please click the "Submit Application" box only once)