APPLICATION FOR PGY-1 RESIDENCY
Application Process:

Due January 1, 2016 via PHORCAS
o Completed application (NEEDS UPLOADED TO PHORCAS)
o Curriculum Vitae
o Three letters of recommendation from professional references
 the ASHP standard recommendation form is required
o Official College of Pharmacy transcripts
FIRST NAME
LAST NAME
ADDRESS
CITY, STATE ZIP CODE
TELEPHONE NUMBER where you can be reached
EMAIL ADDRESS
What prompted your interest in the CPS/Mercy Residency Program
Are you legally authorized to work in the United States?
□ Yes
□ No
Are you eligible for pharmacist licensure in the state of Illinois?
□ Yes
□ No
Have you ever worked for Comprehensive Pharmacy Services?
□ Yes
□ No
Have you ever pled "guilty" or "no contest" to, or been convicted of, a felony,
misdemeanor, or minor traffic violation (e.g., speeding, failure to yield, etc.)? If yes,
include the name and location of the court, the date of the action and, if applicable,
the date that the probation or confinement ended.
□ Yes (please provide any additional explanation in an attached document) □ No
Have you been convicted of a drug or alcohol-related offense, or been subject to a
deferred adjudication for this offense (e.g., Public Intoxication, DWI, Driving Under
the Influence of Drugs)? If yes, include the name and location of the court, the date of
the action and, if applicable, the date that the probation or confinement ended.
□ Yes (please provide any additional explanation in an attached document) □ No
Application Questions
Please note, please keep your responses to a maximum of 250 words per question. (Add
additional paper/pages/space, as needed.)
1.
Why are you pursuing a residency and what characteristics make up your ideal program?
2.
Please describe your current pharmacy practice interests.
3.
How will residency training affect your short and long term goals?
4.
What aspects of the program at CPS/Mercy Hospital and Medical Center do you find
particularly appealing and pertinent to your particular goals?
5.
Briefly describe a mentor/role model in your professional development.
Self – Evaluation
Relative to other pharmacy residency applicants, How would you rate yourself for each of the
following characteristics?
Please place an X under the rating column which best describes your self-evaluation.
CHARACTERISTICS
EVALUATED
Quality of work
Written communication skills
Oral communication skills
Leadership skills
Initiative and motivation
Assertiveness
Cooperativeness
Ability to organize and manage time
Ability to work with supervisors
Ability to work with peers
Ability to work with patients
Dependability
Willingness to accept constructive
criticism
Commitment to professional
practice
Upper 10%
Upper 25%
Upper 50%
Lower 50%
REFERENCES:
Name
Email/phone #
City
Position
1.
2.
3.
EMPLOYMENT HISTORY:
Please list most recent employment first. Please mark if we can contact your prior
employer(s).
Employer
□ Full time
Address:
Date hired:
□ Part time
Position:
Date left:
Supervisor:
Phone:
Reason for leaving:
□ Full time
□ Part time
Position:
Address:
Date hired:
Supervisor:
Phone:
Reason for leaving:
□ Full time
□ Part time
Position:
Address:
Date hired:
Supervisor:
Phone:
Reason for leaving:
□ Full time
□ Part time
Position:
Address:
Date hired:
Supervisor:
Phone:
Contact?: □ Yes
□ No
Employer
Date left:
Contact?: □ Yes
□ No
Employer
Date left:
Contact?: □ Yes
□ No
Employer
Contact?: □ Yes
□ No
Date left:
Reason for leaving:
EDUCATION HISTORY:
High School
Address:
Years attended:
Did you graduate?
College
Address:
Years attended:
Did you graduate?
College of Pharmacy
Address:
Years attended:
Did you graduate?
Other
Address:
Years attended:
Did you graduate?