Employment Application 2022 OLD Version 1

Dear Applicant,

Thank you for your interest in KAVIDA HEALTHCARE where our mission is to provide exceptional health care services with an ethical and holistic approach to care for all clients.

We kindly request that you complete the following online form.

All information you provide will be kept confidential.

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.
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 :*
Company Phone Number
Please enter a valid phone number.
Address:
Supervisor's Name *
We may contact this person for reference.
Supervisor's Phone Number*
We may contact this person for reference
Position:*
What was your position there?
From:
To:
Reason for Leaving:
Company 2 :
Company Phone Number
Please enter a valid phone number.
Address:
Supervisor's name
We may contact this person for reference
Supervisor's Phone Number
We may contact this person for reference
Position
What was your position there?
From:
To:
Reason for Leaving:
How did you hear about us?*
What is his/her name ?

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.
Date of Birth
MM-DD-YYYY
Employee's E mail Address
example@example.com
Employee phone number
Please enter a valid phone number.
1. A citizen of the United States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident4. An alien authorized to work until (expiration date, if applicable)
Alien Registration Number/USCIS Number:
1. Alien Registration Number/USCIS Number:
2. Form I 94 Admission Number:
Expiration Date (if applicable)

MonthDayYear
Date
3. Foreign Passport Number:
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.
(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 $200,000 or less ($400,000 or less if married filing jointly):
How many qualifying dependents do you have?*
Child must be 17 or younger as of December 31, must be your dependent and generally lives with you
Multiply the number of qualifying children under age 17 by $2,000
Child must be under age 17 as of December 31, must be your dependent and generally lives with you
How many OTHER dependents are you claiming?*
Example: Child older than 17, or a qualifying relative and is your dependent when filing your tax
Multiply the number of other dependents by $500
Ex . Child older than 17, or a qualifying relative and is your dependent when filing your tax
Add the amount above and enter the total here.
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
Full name
First and Last name
Address

Street Address

Apt/Unit #

CityState

Postal / Zip Code
CLAIM YOUR WITHHOLDING EXEMPTIONS FOR THE STATE OF MA
Social Security no.
1. Your personal exemption. Write the figure " 1 " but If you are age 65 or over or will be before next year, write " 2 "
if you are less than 65 years old, type 1
2. a - If single or married but not claiming spouse, write "0" . b - If married and will claim your spouse, write the figure "4." . c - If your spouse is age 65 or over or will be before next year and if otherwise qualified, write "5."
If single or married but not claiming spouse, write "0"
3. Write the number of your qualified dependents.
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 #
Account #
Checking AccountSavings Account

Hiring documents
The following documents are needed for hiring. If available at this time, feel free to upload them on the next page.

If not available now, at a later time, you may:

send a picture of them to 781-417-5001

or

fax them to 781-417-5002

or

email them to info@kavidahealthcare.com

List of hiring documents:
1. Driver’s License (or State ID Card)
2. Social Security Card
3. If not a US Citizen, (Permanent resident card or Valid Work Authorization)
4. Professional License/Certificate ( for C.N.A/HHA ONLY)
5. TB Clearance (ONLY 1 needed)
  1. TB Test (less than 1 year) OR
  2. Copy of Chest Xray (less than 5 years) OR
  3. QuantiFERONTB Gold (QFT)(less than 10 years)
6. Current physical(must be less than 1 year)
7. CPR (LPN and RN ONLY)
8. Dementia Training (must be less than 1 year)
9. Covid Vaccination Card
10. Voided check for Direct Deposit

If available now, please submit a CLEAR picture of any of the documents below.
Government ID (Driver's License/Mass ID or Passport)

Cancelof
Social Security Card

Cancelof
Current Physical

Cancelof
TB Test or Chest x-ray or QuantiFERON

Cancelof
CPR (LPN and RN ONLY)

Cancelof
Voided Check for Direct Deposit

Cancelof
Dementia Training

Cancelof
Covid Vaccination Card

Cancelof

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

Hiring documents