Application

Applicant’s legal name:

First Name

Middle Initial

Last Name

Street Address

City

State

Zip Code

Date of Birth

Male

Female

Primary Contact Number

Home Phone

Cell Phone

Email Address

What is your primary language?

Current School/Day program: (if any)

Name and contact number:

Emergency Contact:

Name

Relationship

Address

Phone/Cell

E-Mail Address

Support Contact

Please use the best contact that will be available to reach during class time.

Name

Relationship

Phone/Cell

E-Mail Address

About You

Why do you want to participate in the RI MAP Workforce Training? Tell us about yourself.

Please complete the information below. Information is imperative to complete a CVS application.

Employer &/or volunteer site

Job Title

Supervisor

Paid or unpaid?

Responsibilities

Start Date +

End Date +

Employer &/or volunteer site

Job Title

Supervisor

Paid or unpaid?

Responsibilities

Start Date +

End Date +

Employer &/or volunteer site

Job Title

Supervisor

Paid or unpaid?

Responsibilities

Start Date +

End Date +

Employer &/or volunteer site

Job Title

Supervisor

Paid or unpaid?

Responsibilities

Start Date +

End Date +

Employer &/or volunteer site

Job Title

Supervisor

Paid or unpaid?

Responsibilities

Start Date +

End Date +

Transportation:

How will you get to classroom and externship locations? Please explain.

History:

Have you ever been fired or asked to leave a job or worksite? If yes, please explain:

Yes

Have you quit a job or worksite? If yes, please explain:

Yes

Medical Concerns/Diagnosis (including medications, allergies or other concerns)

Have you ever applied to CVS?

Yes

If yes, please provide us with the date you submitted your application. +

Please be prepared to provide us with your CVS log-in information during the first week of class. (This is very important as CVS has strict guidelines when you can reapply and retake the virtual tryout).

In the past six months, have you submitted applications to any other business?

Yes

Adaptations/accommodation you may need to work or assist you in the classroom:

How do you learn best?

How do you handle redirection, constructive criticism?

How would we know if you were upset, nervous, and uncomfortable?

List three references:

If possible, one of your three references should include a professional reference. This is someone who can give insight about your character, work ethic, reliability, etc. Examples of possible professional references are: a previous employer, supervisor, colleague, co-worker, volunteer organization, teacher, mentor, church.

#1 Name

Relationship:

Phone Number

E-mail address:

#2 Name

Relationship:

Phone Number

E-mail address:

#3 Name

Relationship:

Phone Number

E-mail address:

Education:

Please list the last certificate or diploma you completed.

Name of High School/College/Vocational:

Street Address

Address Line 2

City

State

Zip Code

Education Start Date +

Education End Date +

Graduation Year

Date Diploma received +

Major Area of Study

BCI Requirement

CVS requires that all students placed in externships have a current (within the past 60 days) BCI background check. All participants in the AccessPoint RI/CVS Workforce Development Program are required to have the BCI accomplished before the first day of class. Students must bring the BCI background check with them on their first day of class.

Information on obtaining BCI background checks can be found on the Attorney General’s Website: www.riag.gov