Xincon 家庭保健就业申请表 2026

Xincon Home Health Care Employment Application Form 2026
Section 1: Basic Information
First Name*
Middle Name
Last Name*
M中间名首字母
Maiden Name
Mother’s Maiden Name
Other name used (If any)
Date of Birth*

MonthDayYear
Date
Weight (lbs)
Xincon Employee ID (If any)
Last 4 digits of ssn
EnglishSpanishMandarinCantoneseOther
Address
Apartment
Street Number*
Street Name*
City*
County
State*
Zip Code*
Cell Phone Number*
Please enter a valid phone number.
Other Phone number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name:*
Relationship*
Emergency Contact Phone Number*
Please enter a valid phone number.
Section 2: Notice and Acknowledgement of Pay Rate
Employee's rate of pay (per hour)
My primary language is*
I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary language.
New York City + 401A/Benefit Card + PTONew York City + PTOLong Island + PTOLong Island + Benefit Card + PTO
Type of supplement 1
Type of supplement 2
Name & Address of Provider 1
Name & Address of Provider 2
Agreement 1
Agreement 2
401 retirement planBenefit CardNone
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Overtime Pay Rate(s) for each type of work or shift:
Per hour(This must be at least 1.5 times the workers regular rate with few exceptions.)
Section 3: NEW YORK STATE DEPARTMENT OF HEALTH

Criminal History Record Check
Have been convicted of a crime in New York State or any other jurisdictionHave not been convicted of a crime in New York State or any other jurisdiction
Do have a final finding of patient or resident abuseDo not have a final finding of patient or resident abuse
Section 4: Employee’s Withholding Certificate W4

▶ Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.▶ Give Form W-4 to your employer.▶ Your withholding is subject to review by the IRS.
Single or Married filing separatelyMarried filing jointly (or Qualifying widow(er))Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Number of Children under 17 years old (Enter 0 if none)*
Number of Dependent (Enter 0 if none)*
$
$
Total $
YesNo
Other Adjustments:
4a. Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income
4b. Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here
4c. Extra withholding. Enter any additional tax you want withheld each pay period
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1. Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have onejob, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3
2.Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.
2a) Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying jobin the “Lower Paying Job” column. Find the value at the intersection of the two household salariesand enter that value on line 2a
2b) Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b
2c) Add the amounts from lines 2a and 2b and enter the result on line 2c
3. Enter the number of pay periods per year for the highest paying job. For example, if that job paysweekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc
4. Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional amount you want withheld)
Step 4(b)—Deductions Worksheet (Keep for your records.)
1. Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income
2. Enter:

$29,200 if you’re married filing jointly or qualifying widow(er)
$21,900 if you’re head of household
$14,600 if you’re single or married filing separately
2
3. If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-”
4. Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information
5. Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4
HEPATITIS B VACCINE PROGRAM
I do not wish to be given the Hepatitis B Vaccine at this time. I am aware that I may request to be provided the vaccine at a later date during my employment with the agency.
TB QUESTIONNARE FORM
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

8.Do you have any of the following risk factors which may substantially Increase the risk of tuberculosis?

Rows	Yes	No
a. Silicosis (Lung Disease)
b. Gastrectomy
c. Intestinal Bypass
d. Weight 10% or more below ideal body weight?
e. Chronic Renal Disease
f. Diabetes Mellitus
h. Hematologic Disorder I.e. leukemia or lymphoma
i. Exposure to HIV or AIDS
j. Other malignancies

Section 5: Authorization for Direct Deposit - Employee Form

This authorizes XINCONHOME-HEALTHCARESERVICESINC(the "Company") to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my (our) account(s) indicated below and to other accounts I (we)identifyinthefuture(the"Account"). This authorizes the financial institution holdingthe Account to post all such entries. Note: Enter your company name in the blank space above.
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Section 13: Individual Characteristics Form (ICF)Work Opportunity Tax Credit
YesNo
If yes, enter last date of

MonthDayYear
Date
YesNo
If YES, enter your date of birth

MonthDayYear
Date
YesNo
YesNo
If YES, enter name of primary recipient
city and state where benefits were received
YesNo
YesNo
YesNo
YesNo
YesNo
If YES to either question, enter name of primary recipient
and city And state where benefits were received
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If YES, to any question, enter name of primary recipient
and the city and state where benefits were received
YesNo
If YES, enter date of conviction
date of release

MonthDayYear
Date
FederalState conviction
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If YES, what state did you receive unemployment compensation in?
Sources used to document eligibility: (Employers/Consultants: List all documentation provided or forthcoming. For SWA Staff: List all documentation used in determining target group eligibility and enter your initials and date when the determination was made.
Signature
Date*

MonthDayYear
Date
If you are applying for the Xincon PCA Training Program, please click here to review the training acknowledgment form. By selecting the pre-checked box, you confirm that you have read and fully understand the contents of the Trainee Rights and have had the opportunity to ask any questions. Your signature below acknowledges your agreement to and acceptance of all the terms and conditions outlined in the form.
护理员图片签名
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SSN#:
Employee Name and Address
20 W 33rd Street, Ste. 2006A
New York, NY 10001
Employee Identification number (EIN)
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审查人员图片签名
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Section 8: EMPLOYMENT VERIFICATION AND REFERENCE CHECK 1
Agency Name:
Attention to
Company phone number
Please enter a valid phone number.
Company fax number
Please enter a valid phone number.
EMPLOYMENT VERIFICATION AND REFERENCE CHECK 2
Agency Name:
Attention to
Company phone number
Please enter a valid phone number.
Company fax number
Please enter a valid phone number.
Section 10: Required Xincon Home Health Care Medical Insurance Election/Waiver Form

If you are not interested in Major Medical Insurance, you will need the below waiver form signed and returned to: Xincon Home Health Care Services, Inc. at 20 West 33 rd Street, Suite 2006A, New York NY 10001 Eligible employees who waive their Medical Coverage will be enrolled in Supplemental Benefits.Please check the appropriate box and fill out the form below. All employees must select either the Major Medical Plan or the Supplemental Plan. For supplemental plan, employees must select a supplemental option. If Xincon Home Health Care Services didn’t receive the election/ waiver form by February 28 , 2019, employees will automatically enter to supplemental option 1.
Major Medical. I choose the affordable care act compliant (Costs Employee 9.69% of monthly salary)Supplemental Plan: I choose the Supplemental Plan which satisfies the individual mandate under the Affordable Care Act. -Retirement Plan package (No Cost to Employee)
Enrolling in Supplemental benefitsSpousal CoverageMedicaid/ MedicareVA InsuranceOther- Please specify
Section 9: Home Care Workers Seasonal Influenza Vaccine Requirement

Pursuant to 10 NYCRR § 766.11I understand that as an employee of a New York State Licensed Home Care Services Agency, I amstrongly encouraged--but not required--to receive the annual influenza (flu) vaccine . the purpose of thevaccine is to protect myself, my patients/clients, and my colleagues from influenza illness and itscomplications. The flu vaccination is voluntary.
I have already received the Influenza Vaccine.Documentation ProvidedI am choosing to decline the influenza vaccination for the current flu season. Reason for declination (optional)
Received by

MonthDayYear
Date
MedicalReligiousPersonal/Other
Section 12: Pre-Screening Notice and Certification Request for the Work Opportunity Credit
Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.Check here if any of the following statements apply to you.• I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9months during the past 18 months.• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (foodstamps) for at least a 3-month period during the past 15 months.• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Workprogram, or the Department of Veterans Affairs.• I am at least age 18 but not age 40 or older and I am a member of a family that:a. Received SNAP benefits (food stamps) for the past 6 months; orb. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.• During the past year, I was convicted of a felony or released from prison for a felony.• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.Check here if you are a member of a family that:• Received TANF payments for at least the past 18 months; or• Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginningafter August 5, 1997, ended during the past 2 years; or• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum timethose payments could be made.Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that periodyou received unemployment compensation.
Section 3: Employment information
YesNo
YesNo
How many hours a week are you available for work:
Evening?Weekends?
YesNo
If yes, by Whom?
YesNo
If yes, Driver's License #
If you checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
Section 4: Employment Eligibility Verification
1. A citizen of the United States2. A noncitizen national of the United States See Instructions3. A lawful permanent resident Enter USCIS or A-Number4. A noncitizen (other than Item Numbers 2. and 3. above)
3. A lawful permanent resident Enter USCIS or A-Number
Authorized to work until (exp. date, if any)

MonthDayYear
Date
If you check Item Number 4., enter one of these:
USCIS A-Number
Form I-94 Admission Number
Foreign Passport Number and Country of Issuance
Preparer Name
Should be Empty:

Xincon Home Health Care Employment Application Form 2026

Section 1: Basic Information

Address

Section 2: Notice and Acknowledgement of Pay Rate

Section 3: NEW YORK STATE DEPARTMENT OF HEALTH

Section 4: Employee’s Withholding Certificate W4

HEPATITIS B VACCINE PROGRAM

TB QUESTIONNARE FORM

Section 5: Authorization for Direct Deposit - Employee Form

Section 13: Individual Characteristics Form (ICF)Work Opportunity Tax Credit

Section 8: EMPLOYMENT VERIFICATION AND REFERENCE CHECK 1

EMPLOYMENT VERIFICATION AND REFERENCE CHECK 2

Section 10: Required Xincon Home Health Care Medical Insurance Election/Waiver Form

Section 9: Home Care Workers Seasonal Influenza Vaccine Requirement

Section 12: Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Section 3: Employment information

Section 4: Employment Eligibility Verification