• Note: Jotform uses Secure Sockets Layer (SSL) technology for both server authentication and data encryption, helping to ensure that your data is safe and secure.

  • KL Gash & Associates, LLC

    Hire Employment Package

  • Welcome to KL Gash & Associates, LLC! We look forward to working with you and hope you enjoy your working experience with us. 

    KL Gash & Associates, LLC is an EEO/Affirmative Action Employer committed to excellence through diversity.  Employment offers are made based on qualifications, and without regard to race, sex, religion, national or ethnic origin,  disability, age, veteran status, or sexual orientation. 

    • Please complete the required areas (marked with a red asterisk * )  throughout the packet.
    • When finished, you will need to electronically submit this packet by clicking on Submit at the end. An option to print a copy of this form is available at the end.  
    • You will need to complete W-4, I-9, Authorization for Direct Deposit, and Acknowledgment of Receipt of Employee Handbook which will be generated by filling out this New Hire Employment Package.
    • All items must be submitted prior to starting your employment with us.  
    • Please contact us at info@klgashassociates.com if you have any questions about your employment with KL Gash & Associates, LLC. 

  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  •  -
  • Are you a U. S. Citizen
  • if no, are you authorized to work in the US?
  • Have you ever been convicted of a felony?
  • Ethnic Origin*
  • Veteran*

  • Emergency Contact Information

  • Relationship to Self*
  • What is the best way to contact them in the event of an emergency?*

  • Please provide phone numbers, specifically the number they are best to be contacted on.

  •  -
  •  -
  •  -

  • Position and Availability

  • What position are you applying for?

  • Education

  • Did you graduate?
  • Did you graduate?
  • Browse Files
    Cancelof

  • W-4

  • The link to the Federal Form W-4 is below. A new tab will open when you click on it. The form is a fillable PDF that you will be able to download with your changes filled in. Complete Page 1, steps 1 through 4. Once you have referred to the instructions and withholding calculator that accompany the form, download the completed form with your changes to your computer. 

    Click Here to View and Fill-In the Federal Form W-4

  • Browse Files
    Cancelof

  • You will sign your completed W-4 form at the beginning of your first shift with your manager.

  • Form VA-4

  • The link to the Virginia State Tax Form VA-$ is below. A new tab will open when you click on it. The form is a fillable PDF that you will be able to download with your changes filled in. Complete Page 1 to the signature section of the form. Once you have referred to the instructions that accompany the form, download the completed form with your changes to your computer.

    Click here to View and Fill in the Virginia VA form

  • Browse Files
    Cancelof

  • Authorization for Direct Deposit

  • KL Gash & Associates, LLC REQUIRES all employees to use direct deposit for their paychecks. 

  • The link to the Authorization for Direct Deposit is below. A new tab will open when you click on it.The form is fillable and you will be able to download it to your computer with your information and signature filled in. 

    https://pdpr-client.com/wp-content/uploads/2021/02/Direct-Deposit-Authorization.pdf

  • Browse Files
    Cancelof

  • Professional Experience

  • Clinical Information

    (This sections is to be completed if you are applying for a clinical therapist position)
  • Do you hold a certification(s)?
  • Browse Files
    Cancelof
  • Are credentialed with any insurances?
  • If yes, which one

  • Do you have malpractice insurance?
  • Browse Files
    Cancelof
  • Clinical Expertise (select all that applies)
  • Clinical Trainings (select all that apply)

  • Preferred Client Population (select all that applies)

  • Professional References

  •  -
  •  -

  • Professional Bio and Picture

    (Please upload bio and professional picture to be added the company website)
  • Browse Files
    Cancelof

  • Employee Handbook

  • Once you have reviewed the Employee Handbook, you will be required to acknowledge you have read and understand all the req

    Employee Acknowledgement of Receipt of Employee Handbook

  • Disclosure Questions

  • 1. Has your professional license or registration ever been terminated, stipulated, restricted, limited, conditioned, suspended, revoked, refused, voluntarily relinquished, or not renewed by any licensing board or any health-related agency organization, or is there a review pending?
  • 2. Has your professional license or registration ever been investigated or is it currently being investigated and, if so, what were the results?
  • 3. Has your membership, participation, clinical privileges, or employment ever been denied terminated, stipulated, restricted, refused, limited, suspended, revoked, or not renewed by any peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization, or is there a review pending?
  • 4. Have you ever been reprimanded, censored, or otherwise disciplined by, or have you ever been subject to a corrective action agreement/plan with any licensing board, peer review organization, third party payer, clinic, hospital, medical staff, or any health-related agency or organization?
  • 5. Are there any charges pending or are you currently charged with or have you ever been indicted or found guilty of a felony, gross misdemeanor, misdemeanor, or other offense?

  • Acknowledgment

  • Required*
  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: