Employment Application

Dear Applicant,

Thank you for your interest in KAVIDA HEALTHCARE, where our commitment is to deliver outstanding healthcare services with an ethical and holistic approach for all our clients.

Kindly, take a moment to fill out the online form provided. Rest assured, all the information you provide will be handled with the utmost confidentiality.

We look forward to receiving your completed online application.

Sincerely,

Kavida Healthcare Team

Emergency Contact
Name of person to contact:*
Who to call in case of emergency?
His or her cell phone number:*
We'll call this number in case of emergency.Format: (000) 000-0000.
His or her relationship to you:*
What is his/her relationship to you?

Military Service
YesNo
Branch of Service:
Dates of Service:
Highest Rank Achieved:
YesNo

Employment History
Company 1 :*
Address of Company 1:
Optional
Company Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor's Name *
We may contact this person for reference.
Supervisor's Phone Number*
We may contact this person for reference Format: (000) 000-0000.
Position:*
What was your position there?
From:*
To:*
Type NA if not applicable
Reason for Leaving:
Company 2 :*
Address of Company 2:
Optional
Company Phone Number 2
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor's name*
We may contact this person for reference
Supervisor's Phone Number*
We may contact this person for reference Format: (000) 000-0000.
Position*
What was your position there?
From:*
Type NA if not applicable
To:*
Type NA if not applicable
Reason for Leaving:
How did you hear about us?*
What is his/her name ?
Name of Kavida's Employee

Disclaimer and Signature
I authorize Kavida Healthcare, Inc. to release my information acquired during my hiring and placement to any client facilities for seeking and confirming assignments. Information to be shared might include but is not limited to my employment application, resume, results of background check, completed references, skills checklist, competency assessment test and medical information that the facility may require.

I attest that the above referenced information is true and accurate to the best of my knowledge. I give Kavida Healthcare, Inc. my consent to conduct a reasonable investigation such as CORI, OIG, into my background for the position for which I am applying. If at any time Kavida Healthcare, Inc. discovers that any of the information provided by me is not accurate, my employment may be terminated immediately. I further acknowledge that employment with Kavida Healthcare, Inc. is “at will” and may be terminated at any time for any reason.
Signature*

Clear
Date

MonthDayYear
Today's date
EMPLOYEE REFERENCE CHECK
Name*

Your Last NameYour First Name
Position applying for:
Signature

Clear
Date

MonthDayYear
Date
THIS SECTION WILL BE COMPLETED BY THE PERSON COMPLETING THIS REFERRAL ON YOUR BEHALF.
On a scale of 0 (poor) to 4 (great), how would you rate this person on patient care?

On a scale of 0 (poor) to 4 (great), how would you rate this person for being on time?

On a scale of 0 (poor) to 4 (great), how would you rate this person on working with peers?

Would you want to work with this provider again and why?

Name of person completing this form:

Employment Eligibility Verification

Form I-9
Name

First NameLast Name
Other information (if any)

Middle InitialOther Last Names Used (if any)
Address

Street Address

Apt/Unit #

CityState

Postal / Zip Code
U.S. Social Security no.
Format: 000-00-0000.
Date of Birth
MM-DD-YYYY
Employee's E mail Address
example@example.com
Employee phone number
Please enter a valid phone number.Format: (000) 000-0000.
1. A citizen of the United States2. A noncitizen national of the United States3. A lawful permanent resident4. A non-citizen authorized to work until (expiration date, if applicable)
3. As a lawful permanent resident, (Enter USCIS Number or A-Number)
If selected Option 4, please enter one of the following:
1. Enter USCIS A-Number:
2. Form I 94 Admission Number:
Expiration Date (if applicable)

MonthDayYear
Date
3. Foreign Passport Number and country of Issuance:
Signature of Employee

Clear
Today's Date (mm/dd/yyyy)

MonthDayYear
Date

Employee’s Withholding W-4
Applicant name

First Name and middle initialLast Name
U.S. Social Security no.
Format: 000-00-0000.
(b) Address

Street Address

Unit / Apt #

CityState

Postal / Zip Code
Single or Married filing separatelyMarried filing jointly or Qualifying widowerHead 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
Complete Steps 2–4 ONLY if they apply to you.
Step 2. (Optional) Multiple jobs or Spouse Works- Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Do only one of the following.(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) If there are ONLY two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, MORE TAX than necessary may be withheld.
Step 3. Claim Dependents

If your income will be (a) $200,000 or less - (b) $400,000 or less if married filing jointly:
Multiply $2,200 per child under 18.*
The child must be under 18 before December 31st, and a dependent living with you. If you have none, enter 0.
Multiply $500 per adult dependent. If none, enter 0.*
Adult dependent must be 18 or older and will be listed as your dependent on your tax filing. If you have none, enter 0.
Add the amount above and enter the total here.*
Add the last 2 entries
Step 4(optional):Other Adjustments
4.(a) 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 .
4. (b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here .
4. Extra withholding. Enter any additional tax, you want withheld each pay period.
Employee's signature

Clear
Date

MonthDayYear
Date

FORM M-4 MASSACHUSETTS EMPLOYEE’S WITHHOLDING
CLAIM YOUR WITHHOLDING EXEMPTIONS FOR THE STATE OF MA
Full name
First and Last name
Address

Street Address

Apt/Unit #

CityState

Postal / Zip Code
Social Security no.
Format: 000-00-0000.
1.Personal Exemption: Enter "1" if you are under 65 years old but enter "2" if currently 65 or turning 65 before year-end.*
Enter "1" but if you are or will be 65 by January 1 of next year, then enter "2".
2. Filing Status: (a). Single or Married (not claiming spouse): Enter "0". ---- (b). Married (claiming spouse): Enter "4". --- (c). Spouse 65 or older : Enter "5".*
If single or married but NOT claiming spouse, enter "0"
3. Enter the number of your qualified dependents.
Total of children and adults who will be listed as your dependents on your tax filing. If you have none, enter 0.
4. Add the number of exemptions which you have claimed above.
Additional withholding per pay period under agreement with employer.
A. Check if you will file as head of household on your tax return.B. Check if you are blind.C. Check if spouse is blind and not subject to withholding.D. Check if you are a full-time student engaged in seasonal, part-time or temporary employment whose estimated annual income will not exceed $8000.
EMPLOYER: DO NOT withhold if Box D is checked.
I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.
Signed

Clear
Date.

MonthDayYear
Date

DIRECT DEPOSIT AUTHORIZATION FORM
I hereby authorize my employer (hereinafter “Company”) to deposit any amounts owed to me by initiating credit entries to my accounts at the financial institutions (hereinafter “Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Company to my accounts. In the event the Company deposits funds erroneously into my account, I authorize Company to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until Company and Bank have received written notice from me of its termination in such time and in such manner as to afford Company and Bank reasonable opportunity to act on it.
Employee Name:

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Bank Name:
Routing #
Enter Routing #
Account #
Enter account #
Checking AccountSavings Account

Employee Name:

First NameLast Name
Position applied for
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Applicant Information

Education

Emergency Contact

Military Service

Employment History

Disclaimer and Signature

EMPLOYEE REFERENCE CHECK

THIS SECTION WILL BE COMPLETED BY THE PERSON COMPLETING THIS REFERRAL ON YOUR BEHALF.

TB SIGNS & SYMPTOMS ANNUAL QUESTIONNAIRE

Employment Eligibility Verification

Employee’s Withholding W-4

Step 3. Claim Dependents

Step 4(optional):Other Adjustments

FORM M-4 MASSACHUSETTS EMPLOYEE’S WITHHOLDING

CLAIM YOUR WITHHOLDING EXEMPTIONS FOR THE STATE OF MA

EMPLOYER: DO NOT withhold if Box D is checked.

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.

DIRECT DEPOSIT AUTHORIZATION FORM