Dayton Employment Application

PRIMARY CARE SOLUTIONS Employment Application

Before beginning application, please have the following information handy and ready to upload: Driver's License, Social Security Card, HS Diploma or College Degree, Resume, and a Copy of a Voided Check or Signed Letter from Bank with Routing/Account Number
Today's Date*

MonthDayYear
Date
Last four digits of Social Security No*
Personal Data
Federal and/or state law prohibits discrimination because of age, sex, color, creed, race national origin, religion, marital status, veteran or disability. Please refer to appropriate code list where coed entries are required. Please answer all questions on this application as completely as possible SO we can evaluate it properly. This application may be accompanied by a resume.
First Name*
Middle initial*
Last Name*
Current phone number*
Email Address*
example@example.com
Address*

Current Address

Street Address Line 2

CityState

Postal / Zip Code
Zip code*
Address

Mailing address if different from above

Street Address Line 2

CityState

Postal / Zip Code
Zip code
Only U.S. Citizen Aliens who have legal right to work and remain permanently in the U.S. or Aliens who qualify as "intending citizens" under the immigrating reform and control act of 1986 are eligible for employment.
Are you a citizen of the United States?*

YesNo
If "No" What is your visa category status?
Alien registration number
Position Preferences: Please describe the type of work that you would like to do and for which you are best qualified*
Salary Desired Express as an annual amount*
Date available for work*

MonthDayYear
Date
Have you ever been convicted of a felony or a misdemeanor If yes please use an additional sheet to explain each conviction*
EDUCATION
Highest Level of Education Completed
1,2,3,4,5,6,7,8,9,10,11,12, or GED
College

1234
Graduate School

1234

School

	Location	Attendance Dates	Did you Graduate	Type of Degree or Diploma	Major	Minor
High School or GED
College or University
Graduate or Professional School
Vocational or Technical School

Please list specific courses workshops or training you have that are related to the position in which you are applying
Are you 18 years or older?*

YesNo
Have you ever applied for a position at PCS before?*

YesNo
If Yes, when
Are you related/married to any current or previous employee? If Yes, whom?*
How were you referred to PCS?*
1-By your college 2- Employment Agency 3-By an Employee 4-Walk-In 5-Retired 6-Advertisement 7-State Employment
Have you ever worked under any other name? (required for verifying education, work records and references)*
Are you a Veteran? (Yes / No) If yes please list the dates of services:*

Employment References

	Name	Years Known	Organization Position	Home/Business Address	Home/Business Phone
Reference 1
Reference 2
Reference 3

I hereby give Primary Care Solutions permission to contact any employers listed on the previous page before any relevant information.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Employer*
Type of Organization*
Address*
Supervisor*
Date Employed (Month/Day/Year)*

MonthDayYear
Date
Date Separated (mo/yr)

MonthDayYear
Date
Reason for leaving
Phone Number
Starting Salary
Dollar Amount
per
Ending Salary
Dollar Amount
per
Job Duties (Be Specific)
Employer
Job title
Type of Organization
Supervisor
Address
Date Employed (Month/Day/Yr)

MonthDayYear
Date
Phone Number
Starting Salary
Dollar Amount
per
Ending Salary
Dollar Amount
per
Reason for leaving
Date Separated (Month/Day/Year)

MonthDayYear
Date
Job Duties (Be specific)
Employer
Type of Organization
Job title
Address
Supervisor
Date Employed (Month/Day/Yr)

MonthDayYear
Date
Starting Salary
Dollar Amount
per
Reason for leaving
Phone Number
Date Separated (Month/Day/Year)

MonthDayYear
Date
Ending Salary
Dollar Amount
per
Job Duties (Be specific)
CARE Solutions Employment References Name Years Known

information. I hereby give Primary Care Solutions permission to contact any employers listed on the previous page before any relevant
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
I hereby certify that to the best of my knowledge, the information that I have given in this application is accurate and complete. I understand that incorrect or misleading information may result in termination of this application and discharge from PCS employment, if employed.

I have given PCS permission to verify all information I have provided about my education, past employment and activities. I authorize schools, past and current employers (that I approved in the employment section) to release any relevant information.

If employed by PCS I will sign a Disclosure Agreement, in which I agree to protect PCS, the entire right, title and interest materials in certain ideas, inventions and other proprietary/ confidential property developed and/or with PCS, time, employment based upon request a blank copy of this agreement I agree to submit proof of eligibility to work in my the U.S. In consideration for employment, I agree that at any time my employment and compensation can be terminated, with or without cause, by PCS or myself with or without notice.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
If hired, your signature attests that the medical record entries you will make accurately reflects your professional signature. Additionally, you understand that any falsification, omission, or concealment of material fact may subject you to administrative, civil, or criminal liability as it pertains to the services and documentation provided.
Date of Signature*

Clear
Printed (Typed) Name*
Actual Signature with credentials*

Clear
Primary Care Solutions of Ohio Inc.
AT WILL EMPLOYMENT CLAUSE: Employment contract provision indicting that employer or employee may terminate the employment relationship at any time with or without cause.

In consideration of employer entering into this agreement, employee agrees to conform to the policies and rules of employer in effect from time to time. Each party to this agreement also agrees that employee's employment and compensation can be terminated with or without cause, and without prior notice, at any time options of either employee or employer.
Employees Signature*

Clear
Date*

MonthDayYear
Date
Supervisors Signature

Clear
Date

MonthDayYear
Date
Assurance of Confidentiality & Federal Privacy Regulations
I blanks* have agreed to comply with all Confidentiality and Privacy Rules and Requirements in accordance with Federal and Ohio laws and regulations, by virtue of the contractual agreement with Primary Care Solutions of Ohio Inc, and the completion of this Assurance for Confidentiality form.

Confidentiality information includes (but is not limited to) photographs, videotapes, audiotapes, client records, reimbursement records; information stored in automated files, and clinical staff member client files.

I am aware that violation of this agreement could result in disciplinary actions at Primary Care Solutions, Inc, and is a violation of Federal and Ohio laws that could result in civil penalties.
Signed*

Clear
Print Name*
Title
Date*

MonthDayYear
Date
Witness
Date*

MonthDayYear
Date
Primary Care Solutions of Ohio Confidentiality and Non-Disclosure Agreement
In consideration of employment of the undersigned (Employee) by Primary Care Solutions of Ohio (or any successor thereto), and in consideration of the wages and salary to be Paid. Employee agrees to the following:

1. Statement of Confidentiality

Employee hereby attests that in his/her role with Primary Care Solutions, understand and accepts that they have access to the confidential information, but not limited to, client names, addresses and personal data, billing records, accounts, wages financials, and trust funds. Employee further understands that it is a violation of federal and state law to reveal confidential information, and subject to legal action for violation of applicable laws. Employee I also understand that it is against company Policy to reveal confidential information of any type to anymore not privileged to receive such information. Employee pledges absolutely to maintain, during and beyond employment with Primary Care Solutions, the confidentiality and security of this information as well as any of Primary Care Solutions proprietary information. initial here

2. Statement of Non-Disclosure

Employee acknowledges that not to disclose of confidential information to Anyone other than persons authorized by Primary Care Solutions. Employee agrees to safeguard this confidential information.

a. to any other than Primary Care Solutions and officers or other persons, including employees authorizes by Primary Care Solutions, or use or otherwise exploit Employees will not directly or indirectly disclose for the Employee's own Benefit or for the benefit of anyone other than Primary Care Solutions, and Confidential information whether Such material is developed before or after the date of this Agreement or employee's employment with Primary Care Solutions.

b. Employees shall use his or her best efforts to cause all persons or entities to whom any confidential information shall be disclosed by him or her hereunder to observe the terms and conditions set forth herein as though each such person on entity were bound hereby.

c. Employee shall have no obligation hereunder to keep confidential and Confidential Information if and to the extent disclosure of any such information is specifically required by law or if the information has been released to the public by Primary Care Solutions, provided, however, that in the Event discloser is required by applicable law. Employee shall Provide Primary Care Solutions with prompt notice to Such requirement, prior to making any disclosure, so that Primary Care Solutions may seek appropriate protective order.

3. Information, data and Materials constituting Confidential Information Confidential information includes, but is not limited to, such items, as:

a. any patent, patent application, copyright, trademark, trade name, service mark, service names," know-how" or trade secrets.
initial here*
DEPARTMENT of HOMELAND SECURITY
Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services
USCIS Form I-9 OMB No. 1615-0047 Expires 08/31/2019
Form I-9 OMB No. 1615-0047 Expires 08/31/2019
START HERE:
Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form, ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which an because the documentation presented has a future expiration date may also constitute illegal discrimination.
Last Name (Family Name)*
First Name (Given Name)*
Middle Initial*
Other Last Names Used if any
Address (Street Number and Name)*
Apt Number
City or Town*
State*
ZIP Code*
Date of Birth mmddyyyy*

MonthDayYear
Date
Social Security Number*
Employees Email Address*
example@example.com
Type a question*

A citizen of the United StatesA noncitizen of the United States (see instructions)A lawful permanent residentAn alien authorized to work
1 Alien Registration Number/USCIS Number
2 Form I94 Admission Number
Foreign Passport Number
Country of Issuance
Signature of Employee*

Clear
Todays Date mmddyyyy*

MonthDayYear
Date
Preparer or Translator Certification (check one)*

I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator*

Clear
Name*

First Name Given NameLast Name Family Name
Todays Date mmddyyyy*

MonthDayYear
Date
Address*

Address Street Number and Name

Street Address Line 2

City or TownState

ZIP Code
STOP

Employer Completes Next Page
Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services
USCIS Form I-9 OMB No. 1615-0047 Expires 08/31/2019

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

List A Identity and Employment Authorization Document Title
Last Name Family Name
First Name Given Name
MI
Citizenship/Immigration Status
List C Employment Authorization
Document Title
Document Title
Issuing Authority
Document Title
Issuing Authority
Document Number
Issuing Authority
Document Number
Expiration Date if any mmddyyyy

MonthDayYear
Date
Document Number
Expiration Date if any mmddyyyy

MonthDayYear
Date
Document Title
Expiration Date if any mmddyyyy

MonthDayYear
Date
Issuing Authority
Document Number
Expiration Date if any mmddyyyy

MonthDayYear
Date
Document Title
Issuing Authority
Document Number
Expiration Date if any mmddyyyy

MonthDayYear
Date
Additional Information
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.
The employees first day of employment mmddyyyy
Signature of Employer or Authorized Representative

Clear
Todays Date mmddyyyy

MonthDayYear
Date
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employers Business or Organization Name
Employers Business or Organization Address Street Number and Name
City or Town
State
ZIP Code
Last Name Family Name
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative A. New Name (if applicable) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)
First Name Given Name*
Middle Initial
Date mmddyyyy*

MonthDayYear
Date
Document Title
Document Number
Expiration Date if any mmddyyyy

MonthDayYear
Date
Signature of Employer or Authorized Representative

Clear
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
Todays Date mmddyyyy

MonthDayYear
Date
Name of Employer or Authorized Representative
All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
LISTS OF ACCEPTABLE DOCUMENTS
Documents that Establish Both Identity and Employment Authorization

1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine- readable immigrant visa

4. Employment Authorization Document that contains a photograph (FormI-766

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

Documents that Establish Identity

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

3. School ID card with a photograph

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document 6. Identification Card for Use of

9. Driver's license issued by a Canadian Resident Citizen in the United government authority

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Documents that Establish Employment Authorization

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

(1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 4. Native American tribal document

5. U.S. Citizen ID Card (Form I-197)
I-766
DS-1350, FS-545, FS-240
Department of Homeland Security
Examples of many of these documents appear in Part 13 of the Handbook for Employers M-274
Refer to the instructions for more information about acceptable receipts.
Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the requester. Do not send to the IRS.
1 Name as shown on your income tax return Name is required on this line do not leave this line blank*
2 Business name (disregarded entity name if different from above)
Type a question

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipTrust / EstateLimited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. OtherOther
Limited liability company Enter the tax classification CC corporation SS corporation Partnership
Exempt payee code if any
Exemption from FATCA reporting code if any
(Applies to accounts maintained outside the U.S
Address

5 Address number street and apt or suite no See instructions

Street Address Line 2

6 City state and ZIP codeState / Province

Postal / Zip Code
7 List account numbers here optional
Requesters name and address optional
Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN If you do not have a number, see How to geta TIN, later. or Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.
Social security number*
Employer identification number
Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Signature of US person*

Clear
Date*

MonthDayYear
Date
Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. Form 1099-INT (interest earned or paid)

Form 1099-DIV (dividends, including those from stocks or mutual funds) Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.
Form W-4 (2018) Future developments.

For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.

Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply.

For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and

For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.

If you're exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions If you aren't exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately.

Consider using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you're having withheld compares to your projected total tax for 2018. If you use the calculator, you don't need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.

Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you're married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040- ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/ W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P.

Nonresident alien. If you're a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.
Specific Instructions

Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.

Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you're unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.

Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.

Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don't qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of
Form W-4 Department of the Treasury Internal Revenue Service
Your first name and middle initial*
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records. Employee's Withholding Allowance Certificate Whether you're entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. Last name

5Total number of allowances you're claiming (from the applicable worksheet on the following pages) 6 Additional amount, if any, you want withheld from each paycheck 7 I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write "Exempt" here 7 Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee's signature (This form is not valid unless you sign it Date 8 Employer's name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete 9 First date of boxes 8, 9, and 10 if sending to State Directory of New Hires10 Employer identification employment number (EIN)

Home address (number and street or rural route)
Last name*
Address*

Home address number and street or rural route

Street Address Line 2

City or town state and ZIP codeState / Province

Postal / Zip Code
Married but withhold at higher Single rate
2 Your social security number*
Filing Status*

SingleMarriedMarried, but withhold at a higher Single rate
3 Single Note: If married filing separately, check "Married, but withhold at higher Single rate."

4 If your last name differs from that shown on your social security card, check here. You must call 800-772-1213 for a replacement card.
5 Total number of allowances youre claiming from the applicable worksheet on the following pages 5*
6. Additional amount, if any, you want witheld from each paycheck*
As a dollar figure
7 I claim exemption from withholding for 2018 and I certify that I meet both of the following conditions for exemption Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability If you meet both conditions write Exempt here 7
Employees signature This form is not valid unless you sign it*

Clear
Date*

MonthDayYear
Date
8 Employers name and address Employer Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
9 First date of employment

MonthDayYear
Date
10 Employer identification number EIN
CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK
Last Name*
First Name*
Date*

MonthDayYear
Date
Drivers Lic
State Issued
Middle Initial
Address*

Current Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
State and Zip Code*
Social Security Number*
Choose: Male / Female*
This authorization and consent for release of personal information acknowledges that this PCSOH Company, (Hereafter conduct referred investigations to as "Company") whether and/or its agent, Secure Search, may now, or at any time I am assigned to, volunteer with or to, searches of educational the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended; previous employment, including work history, criminal history information on file in local, state, or federal agencies; and motor vehicle records. I understand that these searches will be used to determine work assignment or employment eligibility under the company's employment or volunteer policies. Therefore, I authorize and consent for sull release of records (either orally or in writing) to the authorized representatives of the company. In addition, I release and discharge the company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, expenses, or any other charge or complaint filed with any agency arising from retrieving or reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report. After reading this document, I fully understand its contents and authorize the background verification.
THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE IN THE PAST 5 YEARS

	City/Town	State	Dates From	Dates To
#1
#2
#3
#4

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE. EMPLOYMENT OR PROVES TO BE INCORRECT OR INCOMPLETE THAT GROUNDS FOR THE CANCELING OF ANY AND I UNDERSTAND ALL OFFERS THAT OF VOLUNTEER POSITIONS WILL EXIST AND MAY BE USED AT THE DISCRETION OF THE EMPLOYER.
Signed this blanks* Day of(month) Date blank (year)
Applicant Print Name*
Applicant Signature*

Clear
Fastfingerprints a National Background Check, Inc. company

Your employment is conditional upon passing a state-mandated, fingerprinted background screening. Please book an appointment using the steps below to complete your Ohio Background Check.

1) Scan QR code or navigate to: https://register.fastfingerprints.com/account-entry

2) Select "I Have a Code", enter 1YLO7NCM, and then click "Yes".

3) Enter your zip code into zip code field and select "Search". Select your location then click next. 4) Select your desired date and time, then click next.

5) Complete your personal information; please fill out each box completely and accurately.

6) Enter your payment information.

7) Verify that all information is correct, check both boxes at the bottom of the page, and type your first and last name into the box that will appear as an e- signature. Once you have done this a green "Submit" button will appear in the bottom right-hand corner. NOTE: Your appointment has not been scheduled until the green submit button has been pressed and you've received your email confirmation! You will receive a confirmation email with an appointment ID number. You will need to have this number at the time of your appointment in addition to your photo ID.

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Employee Information Form
* Denotes required field
Name*

First NameLast Name
Type a question*

MaleFemale
Address 1
Address*

Address 2

Street Address Line 2

CityState

Zip
Social Security Number*
Date of Birth*
Date of Hire
Email Address*
example@example.com
Pay Rate (check one)*

HourlySalary
Amount
Type a question

Type option 1Type option 2
Tax Status (check one)*

W-21099
Pay Frequency (check one)*

WeeklyBi-weeklySemi-monthlyMonthlyQuarterly
Federal Filing Status (check one)*

SingleMarriedMarried - at a Higher Single Rate
Amount
Additional Federal Withholding (check one)

Additional Amount WithheldFlat $ Amount
Amount
Allowances
Federal Filing Status (check one)*

SingleMarriedMarried - at a Higher Single Rate
Additional Federal Withholding (check one)

Additional Amount WithheldFlat $ Amount
Amount
Additional State Withholding (check one)

Additional Amount WithheldFlat $ Amount
Amount
Allowances
Direct Deposit Information
Bank Routing
Bank Account
Account Type (check one)

CheckingSavings
Deposit Amount (check one)

Full AmountPartial AmountPartial % (Percentage)
Partial Amount ($)
Partial Percentage (%)
Bank Routing
Bank Account
Account Type (check one)

CheckingSaving
Deposit Amount (check one)

RemainderPartial Amount ($)Partial Percentage (%)
Amount ($)
Amount (%)
PRIMARY CARE SOLUTIONS INC SAFETY HANDBOOK
Employee Signature and Date

Clear
Safety Handbook Acknowledgement
I have received a copy of the Employee Handbook and have had the opportunity to read it or have it read to me. I understand that I am responsible for the information contained in this handbook. I understand that this handbook is intended to provide a condensed version of the policies, procedures, rules, and ethics most often applied to day-to-day work activities and has been prepared for the information and guidance of staff working at Primary Care Solutions of Ohio. I understand that some of the information willchange from time to time because policies are under constant review and are revised when appropriate. I understand that I will be notified in writing if the changes directly affect my employment or expectations of job performance. I understand that other changes will be discussed in staff meetings.

I agree that my employment is terminable at-will, so that both Primary Care Solutions of Ohio and I remain free to end our work relationship. I understand that there is no guarantee of employment made to any staff member, wither expressly or implied, in this handbook. I have read the title Code of Ethical Conduct and understand that I am responsible for the information it contains. I have been given the opportunity to ask questions about the policy.
Name
Date of Hire

MonthDayYear
Date
Date of Training (individual,group)

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Driver's License*

Cancelof
Social Security Card*

Cancelof
Attach a Voided Check or Signed Letter from Bank with Routing / Account Number*

Cancelof
Diploma / College Transcript(s)*

Cancelof
Resume Upload*

Cancelof
Should be Empty:

PRIMARY CARE SOLUTIONS Employment Application

Personal Data

EDUCATION

I hereby give Primary Care Solutions permission to contact any employers listed on the previous page before any relevant information.

Assurance of Confidentiality & Federal Privacy Regulations

DEPARTMENT of HOMELAND SECURITY

USCIS Form I-9 OMB No. 1615-0047 Expires 08/31/2019

START HERE:

LISTS OF ACCEPTABLE DOCUMENTS

I-766

DS-1350, FS-545, FS-240

Examples of many of these documents appear in Part 13 of the Handbook for Employers M-274

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK

THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE IN THE PAST 5 YEARS

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Direct Deposit Information

PRIMARY CARE SOLUTIONS INC SAFETY HANDBOOK