Connecticut   Project Walgreens Referral Tracking Form

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* denotes required fields Applicant First Last Name: Phone: Address: *only city, state are required E-mail:

*1.  How will the individual travel to and from the Walgreens Distribution Center?

Has own transportation (self/family/friend, etc.) Public transportation/bus Paratransit Transportation through the applicant’s LEA (school district)Other(s) (explain) (If you have questions about how to answer Question #1, click here)

2.  Disability(s):

*3.  How will the individual apply to Walgreens?

Through regular Walgreens recruitment (with or without accommodations)

Note: To be considered for any Walgreens position, applicants going through the regular Walgreens recuitment will need to complete a Walgreens employment application at www.walgreens.jobs

Applicant is being referred to the Walgreens Training Program. S/he will need pre-employment training in order to qualify for a job at the Distribution Center. (For further information about the Walgreens Training Program, click here.)

Note: For Walgreens Training Program applicants, a copy of this form, the Walgreens Training Program Screening Tool, along with required attachments must be submitted to:           Bureau of Rehabilitation Services           3580 Main St.           Hartford, CT 06120           Att: Walgreens Coordinator

(If you have questions about how to answer Question #3, click here)

4.  Type of job desired:

Management or Human Resources General Warehouse Work Other (describe below)

Referral source: First Last *Name: *Organization: Address: Phone #: *E-mail:

Note: For your records, the following will appear on the printed copy of the form: I give permission for (name of referring organization) to submit the above information about me to the Connecticut Bureau of Rehabilitation Services (BRS) on BRS’s website, www.ctbrs.org .  The purpose is to inform BRS of my interest in a job at the Walgreens Training Center in Windsor, CT.  This information will assist BRS in planning training, transportation and other resources for prospective Walgreens employees.  To be considered for a job at Walgreens, I must also either fill out a Walgreens job application or participate in the Walgreens Training Program.  I understand that BRS will not release any identifying information about me without my permission.       Applicant (signature)   Date