Clone of Application for Employment
Personal Information
First Name
Middle Name
Last Name
Name - First Last
Name - First and Middle
Name - First and Middle Initial
Name - First and Last 2
Name - Middle Initial
SSN Last 4 Substring
SSN First 3 Substring
SSN - Last 4
SSN - First 3
SSN - Middle 2
SSN Middle Substring
digit 4
digit 5
6
7
digit 8
digit 9
Today's Date
/
Month
/
Day
Year
Date
SSN Space Digits
Age
todays date - date of birth
Age Number
used to calculate under age 40 question
Street Address:
Apartment/Suite #:
Apartment/Suite #:
City:
State:
Please Select
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Street and Apartment
City State ZIP
Full Address - Street/Apt/City/State/Zip
State - application for employment
Mobile Phone Number:
Home Phone Number:
Email Address:
example@example.com
Date of Birth:
/
Month
/
Day
Year
Social Security #:
Gender:
Please Select
Female
Male
Eye Color:
Please Select
Brown
Black
Blue
Green
Hazel
Hair Color:
Please Select
Black
Brown
Blonde
Red
Weight:
Height: Feet
Please Select
2'
3'
4'
5'
6'
7'
Height: Inches
Please Select
1"
2"
3"
4"
5"
6"
7"
8"
9"
10"
11"
What languages do you speak?
English
Spanish
Russian
Chinese
Urdu
Arabic
Other
Country of Birth:
Please Select
United States of America
Dominican Republic
Haiti
Ghana
Russia
Uzbekistan
China
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
Colombia
Comoros
Congo, Republic of the
Congo, Democratic Republic of the
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
The Gambia
Georgia
Germany
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City (Holy See)
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Race:
Please Select
Cacausian
Asian
African American
Latino
Emergency Contacts
Name of Contact
Telephone
Relationship
Contact 1
Contact 2
Are you a resident of New York City?
Yes
No
Are you a resident of Yonkers?
Yes
No
Are you a resident of New York City? - Mapped
Yes
No
Are you a resident of Yonkers? - Mapped
Yes
No
Which one of our offices are you closes to?
Brooklyn
Queens
Far Rockaway
Bronx
How did you hear about Quality Healthcare?
Please Select
Online
Newspaper
Friend
Other
W4 & I9
Marital Status
Single or Head of Household
Married but Filing Separately
Married but Filing Jointly
Total number of children UNDER age 17
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Other Dependents
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Are you a U.S. Citizen?
Please Select
Yes
No
Are you a lawful permanent resident?
Please Select
Yes
No
Are you an alien authorized to work?
Please Select
Yes
No
If not, give Visa # and expiration:
**
Sorry, we cannot accept your application at this time. Please start your application over again
**
Have you been convicted of a crime?
Please Select
No, I have not
Yes, I have
Have you have a final finding of patient abuse?
Please Select
No, I have not
Yes, I have
If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
Were you ever fingerprinted before at another Home Care Agency?
Yes
No
Availability
Are you currently working as an HHA?
Please Select
Yes
No
Are you currently working as an HH? - Mapped
Yes
No
What shift(s) can you accept?
Hourly
Live-in
Live in Collect
Live in Collect 2
Are you willing to do Live In Work? - Mapped
Yes
No
Can you work a short hour shift? (for example 9am - 1pm)
Please Select
Yes
No
Are you willing to work short hours? - Mapped
Yes
No
Which days of the week can you work?
Availability
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Referred By:
Are there any types of patients you refuse to work with?
Please Select
Bed bound patients
Male patients
Patients with pets
patients who smoke
I can work with ALL types of patients
Education & Employment History
How many years experience do you have?
Please Select
0 to 6 months
6 months to 2 years
2 years and more
What type of certificates do you have?
HHA
PCA
CNA
RN
Other
Do you have a high school diploma?
Please Select
Yes, I have a high school diploma
No, I do not have a high school diploma
Do you have a college degree?
Please Select
Yes, I have a college degree
No, I do not have a college degree
College Degree or Major:
Please Select
College Degree 1
College Degree 2
Other
Training Program:
List below 3 employers, starting with the last one
Name of Employer
Position
Reason For Leaving
Date of Employment - Start
Date of Employment - End
Job 1
Job 2
Job 3
Certifications Mapped
Have you ever worked for this Employer before? Are you a re-hire?
Yes
No
Health Questionnaire
Hep B Vaccine - Please select from one of the following:
I am requesting to receive the Hepatitis B Vaccine
Refuse the Hepatitis B vaccine and hold the agency harmless
Provide written proof of my immunity (I will supply documentation)
Provide written proof of previous vaccination (I will supply documentation)
Provide written proof of medical contraindication (I will supply documentation)
Influenza (flu) Vaccine
Please Select
I have received the flu vaccine this year
I have not received the flu vaccine and I choose to decline
Select One
Benefits & Compensation
How would like to get paid?
Please Select
Direct Deposit
Mailed Check
Office Pick Up
I wish to pick up my check from:
Brooklyn
Queens
Far Rockaway
Bronx
Staten Island (open Fridays 9am-1pm ONLY)
If you are employed as a full time employee (30 hours per week) would you like to enroll in our health benefits plan at an Affordable Level?
Please Select
Yes, I would like to enroll at a minimal cost to me
No, I would like to decline coverage
You are declining coverage, because I have coverage from:
Please Select
My spouse’s employer
Medicare
Medicaid
Union health plan
Another source of coverage
Insurance Name
Policy Number:
Insurance Name:
Policy Number:
Insurance Name:
Policy Number:
Insurance Name:
Policy Number:
Another source of coverage (please specify):
Insurance Name:
Policy Number:
Do you wish to enroll in the Commuter Benefits program
Yes - Accept
No - Decline
Language Application - Mapped
Job 1 Date Range
Job 2 Date Range
Job 3 Date Range
DATE - Application for Employment
/
Month
/
Day
Year
Date
SIGNATURE 1 - Application for Employment
Yes - US Citizen
Non Citizen
lawful permanent resident
alien authorized to work
Citizen Status - Mapped to input boxes on the I9
US Citizen
Non citizen
LPR
alien authorized
Last Name I9-mapped
First Name I9
Address - Street # and Apt - Mapped
City - I9 Mapped
State
Zip
Last Name (Family Name) - ID Mapped
First Name (Given Name) - ID Mapped
M.I.
Citizenship/Immigration Status
Document Title
Document Title
Issuing Authority
Issuing Authority
Document Number
A. New Name (if applicable) - Rehires
B. Date of Rehire (if applicable)
/
Month
/
Day
Year
Date
First name - W4- mapped
Last name - W4 - Mapped
(b) Social security number - W4
Address - W4 - Mapped
street and apartment
Address2 - W4 - Mapped
city state zip
Marital Status - W4
Married but Filing Separately
Married but Filing Jointly
Single or Head of Household
W4 - Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .
Total Under 17
Total Other Dependents
Total Dependents
4(a)
4(b)
4(c)
Employee’s signature W4
Date - W4
/
Month
/
Day
Year
Date
Employer’s name and address
QUALITY HEALTH CARE 3512 QUENTIN ROAD BROOKLYN, NY 11234
First date of employment
/
Month
/
Day
Year
Date
Employer identification number (EIN)
Employer identification number (EIN)
2a
2b
2c
3
Last name
Marital Status IT 2104 Mapped
Single or Head of Household
Married but Filing Separately
Marital status 2 IT 2104 Mapped
Married but Filing Jointly
Apartment number IT 2104 - Mapped
Total number of allowances
Total number of allowances Yonkers
Total number of allowances - NYC
Employer’s name and address
QUALITY HEALTH CARE 3512 QUENTIN ROAD BROOKLYN, NY 11234
If Language is English
English
Other
If l language is not english
Direct Deposit - Mapped
Direct Deposit
Is your mailing address the same as where you live?
Yes
No
Mailing Address - Direct Deposit
Street Address
Apartment / Suite
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Have you been unemployed for at least 27 weeks,and collected Unemployment Insurance?
Yes
No
Have you received Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months?
Yes
No
Are you a Veteran of the US Armed Forces?
Yes
No
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days?
Yes
No
8850 Capture
8850 # 2
Yes
Are you entitled to compensation for a service-connected disability?
Yes
No
8850 # 5-mapped
Yes
Were you discharged from active duty within the last year?
Yes
No
8850 # 4-mapped
Yes
Were you unemployed for a combined total of 6 months before you were hired?
Yes
No
8850 # 3-mapped
Yes
Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?
Yes
No
Are you a member of a family that received SNAP (Food Stamps Benefits)?
Yes
No
Are you currently collecting unemployment benefits?
No
Yes
Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?
Yes
No
Have you received Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
Yes
No
If yes to either question, enter Name of Primary Recipient:
And City, State where benefits were received
If yes to either question, enter Name of Primary Recipient:
Mailing Address - Mapped
Enter a
Employee Name: Authorization - Mapped
LAST Name - DOH CHRC Mapped
FIRST Name - DOH CHRC Mapped
M.I. - DOH CHRC Mapped
Mailing Address (street) - CHRC - Mapped
City - Mapped
State-mapped-CHRC
ZIP CHRC - Mapped
Crime - No
Crime - Yes
Patient Abuse - Yes
Patient Abuse - No
Crime Mapping
NoCrime
YesCrime
Patient Abuse Mapping
YesPA
NoPA
Combined Height - Mapped:
Date of Birth: CHRC - Mapped
/
Month
/
Day
Year
Date
Convicted Of a Crime: CHRC - Mapped
When: Logic Can be applied If needed
Date Fingerprinted: Logic Can be applied If needed
/
Month
/
Day
Year
Date
ACA BENEFIT WAIVER FORM
Employee Name - ACA Waiver Form - Mapped
Declining coverage, mapping
My spouse’s employer
Medicare
Medicaid
Union health plan
Another source of coverage
Home Care Registry Acknowledgement Form
Employee’s Name: - Home care Registry - mapped
SSN - last 4 Home Care Registry Mapped
Date - Home Care Registry
/
Month
/
Day
Year
Date
Employer 1
Employer 2
Employer 3
Position 1
Position 2
Position 3
Reason 1
Reason 2
Reason 3
Date start/end 1
Date start/end 2
Date start/end 3
Have you received Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months. - Mapped
Yes
Have you been unemployed for at least 27 weeks,and collected Unemployment Insurance? - Mapped
Yes
Are you under age 40?
Yes
No
City and State were benefits were received
Print Name: - 8850 - mapped
Social Security # 1: 8850 - mapped
Social Security # 2: 8850 - mapped
Social Security # 3: 8850 - mapped
Date of Birth: - 8850 Mapped
Employment Start Date
Starting Wage - 8850
Have you ever applied to this company before? If so, when?
Last Name (Family Name) Form I9- mapped
First Name Form I9- mapped
Middle Initial - I9
Address (Street Number and Name) Form I9
Apt. Number - Mapped
City or Town - Mapped
State1 I9 - Mapped
ZIP Code - Mapped
Date of Birth I9 - Mapped
/
Month
/
Day
Year
Date
SSN 1 -mapped
SSN Middle 2
SSN Last 4
Employee's E-mail Address-ID - Mapped
example@example.com
Employee's Mobile Number I90 Mapped
(Alien Registration Number/USCIS Number):
(expiration date, if applicable, mm/dd/yyyy): 4. An alien authorized to work until
/
Month
/
Day
Year
Date
1 An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
/
Month
/
Day
Year
Date
2.Form I-94 Admission Number:
3.Foreign Passport Number:
Country of Issuance:
Signature of Employee - I9
Today's Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
M.I. - ID Mapped
Citizenship/Immigration Status
Document Title
Document Title
Document Title
Issuing Authority
Issuing Authority
Issuing Authority
Document Number
Document Number
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Document Title
Issuing Authority
Additional Information
Document Number
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
/
Month
/
Day
Year
Date
First Name of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
sTATE
ZIP
A. New Name (if applicable)
B. Date of Rehire (if applicable)
/
Month
/
Day
Year
Date
Name of Employer or Authorized Representative
First name and middle initial - IT 2104
Your Social Security number - 2104 - Mapped
Address IT 2104 - Mapped
City IT 2104 - Mapped
State - IT 2104 - Mapped
ZIP code - IT 2104 - Mapped
3
4
5
Employee’s signature - IT 2104 - Mapped
Date - IT 2104 - Mapped
/
Month
/
Day
Year
Date
Employer: Keep this certificate with your records. Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):
A
First date employee performed services for pay mm-dd-yyyy see instr:
B Employee is a new hire or a rehire B
First date employee performed services for pay mm-dd-yyyy see instr:
/
Month
/
Day
Year
Date
Are dependent health insurance benefits available for this employee?
Yes No
First date employee performed services for pay mm-dd-yyyy see instr:
If Yes, enter the date the employee qualifies (mm-dd-yyyy):
/
Month
/
Day
Year
Date
Employer identification number - IT 2104
tax year. Total estimate
21 Enter your estimated NY itemized deductions for the tax year (see Form IT-196 and its instructions; enter the amount from line 49) 21
Primary Language - PayRate
Print Employee Name - Pay Rate - Mapped
Employee Signature - Pay Rate
Date - Pay Rate
/
Month
/
Day
Year
Date
My primary language is - Pay rate - mapped
primary language notice - Text
I have been given this notice in my primary language
Yes
No
Employee Name (Print): - Pay Rate - Mapped
Employee Signature: Pay Rate - Mapped
Date Signed: Pay Rate 2 - Mapped
/
Month
/
Day
Year
Date
Signature: direct deposit - mapped
Date: Direct Deposit - Mapped
/
Month
/
Day
Year
Date
Date of Birth DOH CHRC NYS Health - Mapped
/
Month
/
Day
Year
Date
Signature CHRC - 2 - Mapped
Employee Date: DOH NY Dept Health - Mapped
/
Month
/
Day
Year
Date
Signature of Parent or Legal Guardian (if subject individual is under 18 years of age)
Date: Department of Health - Parent
/
Month
/
Day
Year
Date
Agency Name
PFI/Operating License Number:
Print Name of Authorized Person:
Title
Name: CHRC Mapped
Full Address: CHRC Mapped
Mobile Phone Number: CHRC - Mapped
Social Security #: CHRC - Mapped
Employee Signature: CHRC Mapped
Employee Date: HEP B - Mapped
/
Month
/
Day
Year
Date
HR/Recruitment Rep Signature:
Print Name - ACA - Mapped
Date of Birth ACA - Mapped
/
Month
/
Day
Year
Date
Signature ACA Mapped
Date - ACA - Mapped
/
Month
/
Day
Year
Date
EmployeeName 1 - 11 Commuter Benefit - Mapped
Street/Apt Address - Commuter
City/state/zip Address - Commuter
Cell Phone - Commuter
Email - Commuter - Mapped
EmployeeName - 11 Commuter Benefit - Mapped
Employees Signature - 11 - Commuter - Mapped
Date Commuter - 11- mapped
Employee’s Name: Home care registry - Mapped
SSN - Last 4 - Home Care Registry - Mapped
Date:
/
Month
/
Day
Year
Date
Name: First Last - Home Healthcare - Mapped
Email: - Union Card Health - Mapped
example@example.com
Phone: Home Health - mapped
Address - Home Healthcare Workers
this may not fit in the PDF section
Date 1: Home Health - Mapped
/
Month
/
Day
Year
Date
home health dATE collect
Homehealth date 1
Homehealth date 2
Signature: 1 Home Health - Mapped
Date: Home Health - Mapped
/
Month
/
Day
Year
Date
Signature: HomeHealtchare - mapped
DATE: Employment Verification
/
Month
/
Day
Year
Date
EMPLOYER:
ATTN:
PHONE:
FAX:
RE:
Social Security: Employment Verification lsat 4 mapped
Applicant’s Signature - Employment Verification - Mapped
Signature - Home Care
Signature Date - Employment Verification
/
Month
/
Day
Year
Date
Your Full Name - 8850-mapped
Social security number - Mapped
Street address where you live - Mapped
City or town, state, and ZIP code - Mapped
County
Mobile number - 8850 - mapped
Employee signature - 8850 - Mapped
Age Under 40 - 8850
Date
/
Month
/
Day
Year
Date
A Vocational Rehab Agency approved by the state?
No
No
The Dept. of Veteran Affairs?
Yes
No
An Employment Network under the Ticket to Work Program?
Yes
No
Position
Signature
Today’s Date - Mapped
/
Month
/
Day
Year
Date
Full Name: - 17 - HIV Mapped
Signature 1 - 17 - HIV
Signature Date - 17 - HIV Date:
/
Month
/
Day
Year
Date
FULL NAME: 18 - influenza - mapped
Signature 18 - influenza Mapped
Applicant Signature - Master
Date Signed
-
Month
-
Day
Year
Date
Date: Influnza Mapped
/
Month
/
Day
Year
Date
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