Modern Health Home Care

Application for Employment
Office Use Only
I9
Citizenship Status

U.S. CitizenPermanent ResidentAuthorized to Work
Alien Registration Number/USCIS Number
Document Type - LIST A:

U.S. PassportU.S. Passport CardPermanent Resident CardEmployment AuthorizationForeign Passport with I-551
Permanent Resident Card ID Number*
Perm. Resident Card ID Expiration Date*

MonthDayYear
US Passport ID Number*
US Passport Expiration Date*

MonthDayYear
US Passport Card ID Number*
US Passport Card ID Expiration Date*

MonthDayYear
Foreign Passport I-551 ID Expiration Date*

MonthDayYear
Foreign Passport with I-551 ID Number*
Employment Authorization Card ID*
USCIS Number*
Emp. Authorization ID Expiration Date*

MonthDayYear
Document Type - LIST B:

State IDState Driver LicenseState Learner PermitOther State ID with a photographVoter’s Registration CardSchool ID card with a photographU.S. Military or Draft RecordMilitary Dependents ID CardU.S. Coast Guard Merchant Mariner Card
State ID Number*
State ID Expiration Date*

MonthDayYear
Driver License ID Number:*
Driver License ID Expiration Date:*

MonthDayYear
Date
State Learner Permit ID Number:*
Learner Permit Expiration Date:*

MonthDayYear
Date
State ID*
Other State ID Number:*
Other State ID Expiration Date:*

MonthDayYear
Date
Voter Registration ID Number:*
Voter Registration Issue Date:*

MonthDayYear
Date
Name of School *
School ID Card Number:*
School ID Issue Date:*

MonthDayYear
Date
U.S. Military / Draft Record ID Number:*
U.S. Military / Draft Record ID Expiration Date:*

MonthDayYear
Date
Military Dependents ID Card Number:*
Military Dependents ID Card Expiration Date:*

MonthDayYear
Date
U.S. Coast Guard Merchant Mariner Card Number:*
Department Code
U.S. Coast Guard Merchant Mariner Card Expiration Date:*

MonthDayYear
Date
Document Type - LIST C:

Social Security CardBirth CertificateU.S. Citizen ID Card
Birth Certificate Number:*
U.S. Citizen ID Card Number:*
U.S. Citizen ID Card Expiration Date:*

MonthDayYear
Compensation
Orientation Date

MonthDayYear
Base Rate
Other Base Rate
• Working an average of 30 hours per week.
• Working a minimum of 4 weekend shifts per month.
• Working 3 of these Company Observed Holidays:
New Years / Memorial Day / July 4th / Labor Day / Thanksgiving Day / Christmas Day
Program Amount
Enter your own amount:
Office Staff Representative - First Name
Office Staff Representative - Last Name
Office Staff Email Address
Field Staff Coordinator
Office Location
Office Staff Signature

Clear
Personal Information
Applicant Legal First Name*
Applicant Middle
Applicant Legal Last Name*
Home Street Address*
Apartment
City*
State*
ZIP*
County*
Mailing Addresss*

Same as home addressDifferent than home address
Mailing Street Address*
Apartment
City*
State*
ZIP*
County*
Mobile Phone Number*
Home Phone Number
Work Phone Number
Date of Birth*

MonthDayYear
Social Security Number*
Email*
Gender:*
What is your primary language?*

EnglishSpanishRussianChineseArabic
Do you speak any other languages?*

YesNo
What other languages do you speak?*

EnglishSpanishRussianChineseArabicOther
Ethnicity*
Emergency Contact - Full Name*
Emergency Contact Phone Number*
Relationship*
Have you lived in Pennsylvania continuously for the last 2 years?*

YesNo
How did you hear about Home Care agency?*
Why are you interested in employment with us?
Current Marital Status:*

SingleMarriedWidowedDivorced
Legal & Background Checks
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W-4 Tax Related Questions
Marital Status*

Single or Married filing separatelyMarried filing jointly or Qualifying widow(er)Head of household
Total number of children UNDER age 17*
Total number of children OVER age 17*
Extra withholding. Enter any additional tax you want withheld each pay period*
Number only
With this job, will you have another job with similar pay?*

YesNo
Are you a citizen of the United States?*

YesNo
Are you a lawful permanent resident?*

YesNo
Are you an alien authorized to work?*

YesNo
Have you ever plead guilty to or been convicted of a crime?*

YesNo
Please explain:*
Have you ever been listed by a federal agency as debarred, excluded, or otherwise ineligible for participation in federally funded healthcare programs?*

YesNo
Have you been barred from working for a company that participates in government programs such as Medicare/Medicaid?*

YesNo
Do you have any previous names or aliases?*

YesNo
List all names since 1975 (include maiden name, nickname and aliases)
First*
Middle
Last*
Suffix
2 Add Another Alias

Add Another Alias
First*
Middle
Last*
Suffix
3 Add Another Alias

Add Another Alias
First
Middle
Last
Suffix
4 Add Another Alias

Add Another Alias
First
Middle
Last
Suffix
5 Add Another Alias

Add Another Alias
First
Middle
Last
Suffix
Do you have any previous addresses since 1975?*

YesNo
Address 1*
2 Add Another Address

Add Another Address
Address 2
3 Add Another Address

Add Another Address
Address 3
4 Add Another Address

Add Another Address
Address 4
5 Add Another Address

Add Another Address
Address 5
6 Add Another Address

Add Another Address
Address 6
7 Add Another Address

Add Another Address
Address 7
8 Add Another Address

Add Another Address
Address 8
9 Add Another Address

Add Another Address
Address 9
10 Add Another Address

Add Another Address
Address 10
Have you lived with anyone with since 1975. Please include either a parent, grandparent or guardian*

YesNo
Full Name*
(Last, First, Middle)
Relationship*
Present Age*
Gender*
Household Name choice 1
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 2
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 3
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 4
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 5
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 6
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 7
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 8
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Household Name choice 9
Full Name
(Last, First, Middle)
Relationship
Present Age
Gender
Select ONE of the following: *

I have lived in the State of PA for more than 2 years.Copy of Federal Criminal History Report dated less than 2 YEARS from application date was provided to Home Care AgencyFingerprinting Registration completed for Federal Background CheckI have not provided a Federal Criminal History Report nor have I registered for having my fingerprints taken BUT I UNDERSTAND THAT IF APPLICABLE IT MUST BE COMPLETED PRIOR TO MY ACTUAL START DATE.
Availability
Positon applied for:*
Are you currently employed?*

YesNo
May we contact your current employer(s)?*

YesNo
Have you ever worked for us before?

YesNo
What type of employment are you looking for?
Have you ever applied here before?

YesNo
When will you be available to start working with us?*

MonthDayYear
Have you have been given a copy of the job description for the position for you applied for?*

YesNo
Please complete all areas of availability:*

MorningsAfternoonEveningsOvernightsWeekdaysWeekends

Which days of the week can you work?*

	Start Time	End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please indicate all areas of the city in which you are willing to work:*

Bucks Co.Philadelphia Co.Montgomery Co.Chester Co.Delaware Co.Other
Please indicate the types of services which you are willing to provide:*

Activities (games/crafts)CompanionshipDementia/Alzheimer’s CareErrands/Shopping/Transportation*Housekeeping (dust/vacuum)Laundry/IroningLawn Care/GardeningMeal PreparationMedication RemindersPersonal CareWound CareOther
Are you willing to do temporary fill-in hours until the hours you want become available?*

YesNo
Are you available to be On-Call for additional income?*

YesNo
Are you willing to provide service to a client with a pet?*

YesNo
What kind of pet?*

CatDog
Are you willing to provide service to a client that smokes?*

YesNo
Are you able to perform the essential functions of the job for which you are applying with or without areasonable accommodation?*

YesNo
PROOF OF RESIDENCY DOCUMENT(S): (Please check box for the document you are submitting)*

A valid driver’s license or a State-issued identification. (REQUIRED)Housing records, such as mortgage records or rent receipts.Public utility records and receipts, such as electric bills.Local tax records.A completed and signed, Federal, State or local income tax return with the applicant’s name and address preprinted on it.Employment records, including records of unemployment compensation
PROOF OF RESIDENCY DOCUMENT(S): (Please check box for the document you are submitting)

A valid driver’s license or a State-issued identification. (REQUIRED)Housing records, such as mortgage records or rent receipts.Public utility records and receipts, such as electric bills.Local tax records.A completed and signed, Federal, State or local income tax return with the applicant’s name and address preprinted on it.Employment records, including records of unemployment compensation
Do you have a valid driver's license?*

YesNo
Driver's license Number*
State*
Expiration*
Education and Skills
Did you graduate high school?

YesNo
High School Name
High School Location
Major/Subject
Number of years attended:
Did you graduate college ?

YesNo
College Name
College Location
Major/Subject
Number of years attended:
Did you complete any vocational or technical schools?

YesNo
School Name
School Location
Major/Subject
Number of years attended:
Describe any training or life skills you have that apply to caring for adults:
Describe any work history you have that would apply to caring for adult’s:
What do you like (or think you would like) most about caring for people?
What do you like (or think you would like) least about caring for adults?
References
(Do not include relatives)
Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all three references, you will be asked to provide additional references.
Reference 1 Full Name*
Mobile Phone Number*
Work Phone Number
Best time to call
Relationship
Years Known
Reference 2 Full Name*
Mobile Phone Number*
Work Phone Number
Best time to call
Relationship
Years Known
Reference 3 Full Name*
Mobile Phone Number*
Work Phone Number
Best time to call
Relationship
Years Known
Employment History
Include up to 3 past employers below:
First Employer Name*
Position Held*
Supervisor*
Past Employer Phone Number*
Duties*
Salary Amount:*
What is the frequency of the salary you provided above?*
Are you currently working for this employer?*

YesNo
May we contact this employer?*

YesNo
Reason for Leaving*
Past Employer Address*
City*
State*
ZIP*
Start Date*
MM/YY
End Date*
MM/YY
Do you have a second past employer?*

YesNo
Second Employer Name*
Position Held*
Supervisor*
Past Employer Phone Number*
Duties*
Salary Amount:*
What is the frequency of the salary you provided above?*
Reason for Leaving*
Past Employer Address*
City*
State*
ZIP*
Start Date*
MM/YY
End Date*
MM/YY
Do you have a third employer?*

YesNo
Third Employer Name*
Position Held*
Supervisor*
Past Employer Phone Number*
Duties*
Salary Amount:*
What is the frequency of the salary you provided above?*
Reason for Leaving*
Past Employer Address*
City*
State*
ZIP*
Start Date/Orientation Date*
MM/YY
End Date*
MM/YY
Health Questionnaire
Hepatitis B Vaccine - Please select from one of the following:

No, I do not wish to receive the Hepatitis B seriesI have not received the vaccination and am requesting to receive the Hepatitis B VaccineI already have had the vaccination and can provide documentation
Are you from or have you lived for one month or more in Africa, Asia, Central or South America, or Eastern Europe?*

YesNo
List the countries you have visited*
Have you ever resided, worked or volunteered in any of the following facilities?*

PrisonHospitalNursing homeHomeless shelterNo, None of the AboveOther long term treatment center
Have you ever had a positive TB skin test or history of TB infection?*

YesNo

Do you have any of the following risk factors which may substantially increase the risk of tuberculosis?*

Silicosis (Lung Disease)GastrostomyIntestinal BypassWeight 10% of more below ideal body weightChronic Renal DiseaseDiabetes MellitusProlonged high-dose corticosteroid therapy or other immunosuppressive therapyHematologic Disorder (i.e. leukemia or lymphoma)Exposure to HIV or AIDSOther malignanciesNone of the above
Have you ever used injected drugs?*

YesNo
Have you submitted a recent Tuberculosis test to Angels on Call?*

YesNo
HM - TB Name
I hereby authorize Angels on Call to withhold from my wages the total of $50.00 for the QuantiFERON-TB Gold Tuberculosis blood test to aide in the detection of Mycobacterium tuberculosis. *

I Agree
When was your last tuberculin skin test or chest x-ray to rule out TB?*

MonthDayYear
Where was the skin test or chest x-ray given? (City)*
Benefits and Payroll
Health Insurance Benefits:*

I do not wish to enroll at this time and understand that I can enroll in the plan later but my hourly pay rate may be impactedI would like to enroll at this time
Reason for refusal of medical coverage:*

coverage sponsored by other employercoverage sponsored by spose's employerOther
How would you like to get paid?*

Direct Deposit – money should be placed in my own bank accountPay Card – Money will be deposited into a Modern Home Care provided debit card
It can take up to two weeks for direct deposit payments. Please provide HR with a copy of a voided check and select a backup payment method.

Please be aware, any new direct deposit account set up will undergo a pre-note verification where in the new account provided will be validated. This process can take anywhere up to 3 check dates to complete. This means you may receive up to 3 live checks until the pre-note verification is successfully completed and you begin to receive direct deposits to the account. Please make any necessary financial arrangements necessary.
Account Type*

Checking AccountSavings AccountBoth
Amount of Deposit*

Total Net PaySpecified Dollar AmountPercentage of net pay
Enter the $ Dollar Amount*
Enter the % Amount*
Bank / Credit Union Name:*
Bank / Credit Union City:
State
Bank / Credit Union ZIP:*
Account Number*
ABA Transit/Routing Number*
Do you have another checking account to add?*

YesNo
Bank / Credit Union Name:*
Bank / Credit Union City:
State
Bank / Credit Union ZIP:
Account Number*
ABA Transit/Routing Number*
Enter the $ Dollar Amount*
Comments*
Savings Account Details: Bank / Credit Union Name:*
Bank / Credit Union City:
State
Bank / Credit Union ZIP:
Enter the $ Dollar Amount*
Comments
Government Assistance
Have you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit?*

YesNo
Have you, or your family, received SNAP benefits (Food Stamps) in the last 6 months?*

YesNo
Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?*

YesNo
Name of Primary Recipient of Food Stamps (SNAP)*
And City, State where benefits were received*
Have you, or your family, EVER received Temporary Assistance for Needy Families (TANF) or Cash Benefits?*

YesNo
Or, did your family stop being eligible for Temporary Assistance for Needy Families (TANF) assistance within 2 years before being hired, because you reached the maximum time those benefits can be received?*

YesNo
Name of Primary Recipient of Cash Benefits (TANF): *
State
And City, State where benefits are received:*
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days?*

YesNo
I declare that I was in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period I received unemployment compensation*

YesNo
Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?*

YesNo
Unemployed Since:*

MonthDayYear
What state did you receive unemployment compensation in?*
Employee Status & Referrals
Are you a Veteran of the US Armed Forces?*

YesNo
Are you entitled to compensation for a service-connected disability?*

YesNo
Were you discharged from active duty within the last year?*

YesNo
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days, beforeyou were hired?*

YesNo
Were you charge/convicted of a Felony or misdomeanor or served jail time?*

YesNo
Incident:*
City and State where charged:*
Date of Conviction*

MonthDayYear
Date of Release*

MonthDayYear
What type of charge was it?*
Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?*

YesNo
Were you referred to this employer by:*

A Vocational Rehab Agency approved by the state?An Employment Network under the Ticket to Work Program?The Dept. of Veteran Affairs?None of the above / Not Sure
I have reviewed the above PDF of the Employment Application*

Yes
I have reviewed the above PDF of the Job Description*

Yes
Signature*

Clear
Total Hours
Base Rate
Base Rate Overtime
Overtime Hours
Start Date

MonthDayYear
Date

	No	Yes
Have you ever had the BCG vaccine?
Do you have prolonged or recurrent fever?
Have you recently lost weight?
Do you have a chronic cough?
Do you cough up blood?
Do you have sweating at night?

Application for Employment

Office Use Only

I9

Compensation

Personal Information

Legal & Background Checks

W-4 Tax Related Questions

Availability

Education and Skills

References

Employment History

Include up to 3 past employers below:

Health Questionnaire

Benefits and Payroll

Government Assistance

Employee Status & Referrals

Form I9 Fields