Mr's G's - HHA Application

HHA/PCA Application for Employment
For Office Use Only
Citizenship Status

U.S. CitizenPermanent ResidentAuthorized to Work
Alien Registration Number/USCIS Number:
USCIS Number:
Emp. Authorization ID Expiration Date

MonthDayYear
ID Type - Select ALL that Apply

NYC IDState IDState Driver LicenseState Learner PermitState Benefit CardPermanent Resident CardEmployment AuthorizationUS PassportUS Passport CardForeign Passport with I-551None, I do not have any of this information
{nycId} ID Number
{nycId} ID Expiration Date

MonthDayYear
List B expiration date:

MonthDayYear
Date
State Benefit ID Number
Permanent Resident Card ID Number
Perm. Resident Card ID Expiration Date

MonthDayYear
Employment Authorization Card ID
Foreign Passport with I-551 ID Number
Foreign Passport I-551 ID Expiration Date

MonthDayYear
US Passport ID Number
US Passport Expiration Date

MonthDayYear
US Passport Card ID Number
US Passport Card Expiration Date

MonthDayYear
I9 Hire Date

MonthDayYear
Base Rate
Supplemental Wages
Overtime Rate
Send Payrate PDF to user:

YesNo
Personal Information
First Name*
Middle Name
Last Name*
Alias Name
Maiden Name
Mother's Maiden Name
Street Address:*
Apartment/Suite #:
Hidden spacer
City:*
State:*
Zip:*
How long have you lived at this address?*
Mobile Phone Number:*
Home Phone Number:
Email Address :
example@example.com
Date of Birth:*

MonthDayYear
Social Security #:*
Gender:*

FemaleMale
Eye Color:*
Hair Color:*
Weight:*
in pounds
Height*
What is your primary language?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengali
Do you speak any other languages?*

YesNo
What other languages do you speak?*

EnglishSpanishRussianChineseUrduArabicGeorgianUzbekHebrewHindiItalianPunjabiUkrainianYiddishBengali
Country of Birth:*
Race:*
Do you drive?*

YesNo
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship:*
Do you have another Emergency Contact?*

YesNo
Emergency Contact Name:*
First/Last
Phone Number:*
Relationship:*
Availability and Work Preferences
Position applying for:*

Desired work schedule:*

	Start Time	End Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Desired Areas(s):

BronxBrooklynHarlemManhattanQueensLong IslandWestchester
Desired Availability:

WeekendsWeekdaysDaysEveningsNightsHourly8 Hour Shift12 Hour ShiftLive InOther

Work Preferences:*

	Yes	No
Will you work with a client who smokes?
Do you know how to cook?
Are you comfortable working wit ha client using a Hoyer lift?
Are you a licensed driver?
Do you have a car?

Are you allergic to cats?*

YesNo
Are you able to work with a client who has cats?*

YesNo
Are you allergic to dogs?*

YesNo
Are you able to work with a client who has dogs?*

YesNo
Do you prefer to work with:*

Male clients onlyFemale clients onlyBoth Female or Male
W4 & Background
Marital Status*

Single or Head Of HouseholdMarried Filing JointlyMarried Filing Separately
Are you a resident of New York City?*

YesNo
Are you a resident of Yonkers?*

YesNo
Total number of children UNDER age 17*
Other Dependents*
Are you a U.S. Citizen?*

YesNo
Are you a lawful permanent resident?*
Are you an alien authorized to work?
If not, give Visa # and expiration:
HM - legally authorized to work

YesNo
HM - legally authorized to work
**Sorry, we cannot accept your application at this time. Please start your application over again**
Have you had a final finding of patient abuse?*

YesNo
If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
Have you ever worked for this Employer before? Are you a re-hire?*

YesNo
Last Date of Employment

MonthDayYear
Date

Education

	School Name	Location	Did you graduate?
High School
College
Business/Trade School

Do you have any other skills that would benefit this position?
Health Questionnaire
Hep B Vaccine - Please select from one of the following:*

I will receive my Hepatitis vaccine through my primary care physicianRefuse the Hepatitis B vaccine and hold the agency harmlessI have previously received the vaccine
Influenza (flu) Vaccine - If you decline, you must wear a mask!*

I have received or will receive the flu vaccine (between September and May).I decline vaccination: I believe I will get the ﬂu if I get the shot.I decline vaccination: I do not like needles (I would take FluMist nasal vaccine if made available).I decline vaccination: My philosophical or religious beliefs prohibit vaccination.I decline vaccination: I have a medial contraindication to receiving the vaccineOther
Government Assistance
Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?*

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

YesNoNot Sure
Name of Primary Recipient of Food Stamps (SNAP):
And City, State where benefits were received (SNAP):
Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?*

YesNoNot Sure
Are you a member of a family that received TANF benefits for any 18 months beginning after August 5, 1997, AND the earliest 18-month period beginning after August 5, 1997, ended within 2 years before you were hired?*

YesNoNot Sure
Are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired?*

YesNoNot Sure
Name of Primary Recipient of Cash Benefits (TANF):
And City, State where benefits are received (TANF):
Did your family stop being eligible for TANF assistance within 2 years before you were hired because a Federal or state law limited the maximum time those payments could be made?*

YesNoNot Sure
Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days?*

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

YesNo
Employee Status & Referrals
Are you a Veteran of the US Armed Forces?*

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

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

YesNo
Have you been arrested or convicted of a crime before?*

YesNo
Date of Conviction*

MonthDayYear
Date of Release*

MonthDayYear
Type of Felony:*
Please explain:*
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
To the best of your knowledge, are you able to perform all duties required for this position with or without a reasonable accommodation?*

YesNo
Live in Collect
New York Urban Youth Jobs Program
Do you currently meet one or more of the youth categories below?
- I am pregnant or a parent of a child.
- I am over 18 and do not have a high school diploma of GED/HSE diploma.
- I am a member of a family that is receiving assistance from Temporary Assistance for Needy Families (TANF).
- I am a member of a family that is receiving SNAP benefits (food stamps).
- I am a member of a family that is receiving SSI benefits.
- I am receiving a free of reduced-cost school lunch.
- I have served in jail or prison, or am on probation or parole.
- I am currently or was in foster care of the custody of the Office of Children and Family Services.
- I am a veteran.
- I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years.
- I am the daughter or son of a parent who is collecting unemployment insurance.
- I live in public housing or receive housing assistance such as a Section 8 voucher, or am homeless.
- I consider myself to have a different risk factor not identified in the above list.
Agreement:
- I affirm that I meet one of the categories listed above
- I understand that I must provide private, personal information on this application to qualify for the program.
- I understand that I do not need to explain why I qualify to anyone I ask for a job, or who gives me a job, or anyone who I work with.
- I agree to allow the New York State Department of Taxation and Finance to share my wage record with the New York State Department of Labor.
- I believe the information submitted in this application is true, correct and complete.
- I understand that the New York State Department of Labor will make sure the information submitted in this application is true and may ask me for more information or details.
- I am aware that there are consequences for filing false documents or other information with the government.
- I also allow Tax Opportunities of America to submit this application on my behalf.
- If you believe that you do not meet one of the categories (risk factors) listed above, please email info@taxoa.com or call 718-705-9003
I am currently live in one of the below city/town:

New York City (5 boroughs)AlbanyBrookhavenBuffaloHempsteadMount VernonNew RochelleRochesterSchenectadySyracuseUticaYonkersWhite PlainsOther
Are any of the following statements true:
- I am currently unemployed
- I was unemployed prior to completing this application
- I do not have enough paid work
- The work that I have does not make use of my skills and training
Yes No
I have working papers:

YesNo
I am currently enrolled in high school:

YesNo
I am currently enrolled in a High School Equivalency (HSE) program, or have obtained a high school diploma.

YesNo
I have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or I am enrolled in a TASC program.

YesNo
Parent or Guardian Name:
Parent or Guardian Phone Number:
I would like the Department of Labor to contact me by:

PhoneEmail
Signature
Please review the following documents:
By clicking the submit button, I agree to terms & conditions.*

I Agree
Applicant Signature *

Clear
HEP A Decline Applicant Signature

Clear
HEP A Already Have Applicant Signature

Clear

	Yes	No	Comments
Weakness
Unexplained Fatigue for more than 3 weeks
Lack of Appetite
Unexplained Weight Loss
Low Grade Fever
Unexplained Fever, Chills, or Drenching Night Sweats
Flu like symptoms
Chest pains
Shortness of breath
Persistent Cough
Coughing Up Blood/Blood Streaked Sputum
Clear, yellow or dark Sputum
Have you ever been exposed to anyone with the above signs or symptoms or who has had Tuberculosis?

HHA/PCA Application for Employment

For Office Use Only

Personal Information

Availability and Work Preferences

W4 & Background

Health Questionnaire

Government Assistance

Employee Status & Referrals

New York Urban Youth Jobs Program

Signature

Education & Employment History

Education and Work History

References and Referrals

Benefits & Compensation

	Name	Relationship	Phone Number
Reference 1
Reference 2
Reference 3

	Name	Relationship	Phone Number
Referral 1
Referral 2
Referral 3