Request Form Pharmacist

Request Form
Pharmacy name:
Contact Person

First Name Last Name
Email
example@example.com
Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Number of Pharmacy assistance / Technicians
Position Title
Positions available:

Full time Part time Internship Locums
Hours per week required
Days per week required
Do you provide accommodation or rental assistance?
Do you provide relocation assistant
Agreement

Ongoing Contract
Hourly pay rate or annual salary excluding super
Is this rate the base rate and what is theSaturday, Sunday and Public Holiday rate?
Ideal start date
Approximate scripts per day
Pharmacotherapy

yes No
Nursing Home

yes no
POS & Dispense computer system used
Position Details
Position Title
Job Description:
Key Requirements/ minimum of experience
Additional Skills
Should be Empty:

Request Form