Relief Pharmacists of Oklahoma, Inc.

 

Independent Contractor Application for Placement

 
The form below is for a Registered Pharmacist in Oklahoma to apply as an independent contactor to Relief Pharmacists of Oklahoma, Inc. Fill in the information below and then click on SUBMIT below the form. You will also need to fax a photo-copy of your current Oklahoma Pharmacist Registration and a photy-copy of your Pharmacist Liability Insurance Policy to RPO at: 405-737-1750. Upon receipt of all information RPO will review the application and contact you by phone or email .
 
 
Name
  Marital Status Married Single
 
Address line 1
 
Address line 2
 
City
 
State
 
Zip
 
Home Phone
  Cell Phone
 
Work Phone (optional)
  Email Address (optional)
 
Birthdate (optional)
 
SSN (you can call it in if you prefer)
  Are you currently a licensed pharmacist in Oklahoma? Yes No
 
Year Registered
  Do you carry malpractice Insurance? Yes No
  Note: If you need malpractice insurance check the "links" section for Pharmacists Mutual Insurance Co.
 
Outline Your Educational Background (most recent first) Give degrees and Estimated GPA
 
Outline your professional experience including present employer if currently working. Give dates, addresses, approximate salary and whether we can contact past employers for reference.
 
Oklahoma State Pharmacy License #
  Do you now have or have you ever had action against your license with a state pharmacy board? Yes No
  If you answered YES above as ever having an action against your license please explain:
  How did you hear about Relief Pharmacists of Oklahoma?
 
List three individuals for personal reference. GIve their address, phone number, occupation, and length of time you have known them.
 

 

PLACEMENT AGREEMENT

I agree to conduct myself in a professional manner and to abide by all state and federal regulations regarding the practice of pharmacy. I understand that I am NOT an employee of Relief Pharmacists of Oklahoma, Inc., but an independent contractor placed by Relief Pharmacists of Oklahoma, Inc. This agreement in no way limits my ability to seek outisde full or temporary employment. I do agree NOT to circumvent R.P.O.,Inc. after their placement of me at a pharmacy without compensating them for the resultant loss of revenue not exceed 10% of my gross salary for the first twelve months. I do NOT agree to pay any fees and I further understand that this agreement does NOT guarantee placement. Enter your full name and the date below to indicate that you have read and agree to the above. Print a copy of this page as your copy of the agreement.

  Your Full Name (accepting above agreement):    
  Date accepting above agreement: