Job Application Part I: Personal InformationFirst Name *Last Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwePhone Number *Social Security Number *Position Applied ForSelect positionPharmacistCertified Pharmacy TechnicianPatient CoordinatorManagerOtherEmail Address *Additional InformationIs there any information we would need about your name or use of another name for us to be able to check your work record? *YesNoDo you have any relatives who are presently (or have formally been) employed by Capitol Wellness Solutions? *YesNoHave you ever been convicted of a felony? *YesNoHow were you referred to Capitol Wellness Solutions? *Part II: Educational HistoryEducationList your education details starting with the most recent first. Click to add entries as necessary.School *Degree / DiplomaYears CompletedGraduated? *SelectYesNoPart III: Employment RecordCurrent EmploymentCurrent Employer *Name of Current Employer or NONE if not employedPositionName of Current PositionStart DateEnd DateLeave blank if not applicablePhoneAddressCompany AddressManager's NameReason for LeavingPrevious EmploymentList all employment for the last five years, with the most recent first. Click to add positions as necessary.Previous EmployerName of Previous EmployerPositionName of Current PositionStart DateEnd DatePhoneAddressCompany AddressManager's NameReason for LeavingPart IV: ReferencesPlease do not include relatives or former employers.First Name *Last Name *Phone Number *Email Address *OcupationYears KnownPart V: Work AvailabilityIf your application received favorable consideration, when would you be available to begin work? *Do you have any objection to working overtime? *YesNoCan you work overtime without prior notice? *YesNoCan you work on Saturday? *YesNoCan you work on Sunday? *YesNoCan you travel if required by this position? *YesNoSalary / Hourly Rate RequirementsIf your application receives favorable consideration, what salary/hourly rate would you require? *Part VI: Emergency Contact InformationFirst Name *Last Name *Relationship to you *Contact Phone Number (1) *Contact Phone Number (2)Part VII: Background Research ReleasePlease read this section carefully and acknowledge your understanding by checking each of the boxes.Consent To Conduct Background Investigation *As a condition of and in consideration for Capitol (CWS) consideration of this application, I give permission to Capitol to Investigate my personal and employment history. I understand that this background Investigation will include, but not limited to, verification of all information on this application, as well as Interviews with past employers. I further give permission to Capitol conduct this investigation and to discuss the results of this investigation In connection with my application for employment.Consent to Contact Past Employers *I give permission to Capitol to contact all employers listed in this application (except those. specifically excluded) for references. I further give permission to all current or previous employers and/or managers or supervisors to discuss my relevant personal and employment history with AXIA; consent to the release of such information orally or in writing; and hereby release them form all flability and agree not to sue them for defamation or other claims based upon any statements they make to any representative of Capitol I further waive all rights I may have under state law to receive a copy of any written statement provided by any of my former employers to Capitol I further agree to Indemnify all past employers for any liability they may Incur because or their reliance upon this release.Consent to Contact Government Agencies *I give permission to any agent, attorney, or representative of Capitol to receive a copy of my information obtained in the file of any federal, state, or local court, governmental agency, law enforcement agency, or investigator concerning or relating to me. I further consent to the release of such Information and waive any right under state law concerning notification of the request for a release of such information. In the event a state law rines not provide for prospective employers to have access to Information, I hereby delegate Capitol (cwsas my agent for receipt of Information. I understand that the scope of this investigation will be limited to criminal and/or civil records that relate to my honesty, integrity, and/or abilities.Employment "At WII!” *In consideration of my employment, I agree to conform to the rules and regulations of and my employment and compensation Is “at will” in that they can be terminated with or without cause, and with or without notice, at any time, at the option of either 'Capitol (CWSbr myself, except as otherwise provided by law. I understand that no manager or representative of Capitol (CWS), other than the President of Capitol (CWSX or franchise owner for franchise employees only), has the authority to enter into any agreement for employment for any specified period of time or to make any agreement or contract to the foregoing, and that any promises to the contrary will only be relied upon by me If they are in writing and signed by the President of Capitol Wellness Solutions. Submit Form
