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- Citizenship Status
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- Emp. Authorization ID Expiration Date
- ID Type - Select ALL that Apply
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- {nycId} ID Expiration Date
- List B expiration date:
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- Perm. Resident Card ID Expiration Date
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- Foreign Passport I-551 ID Expiration Date
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- US Passport Expiration Date
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- US Passport Card Expiration Date
- I9 Hire Date
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- Send Payrate PDF to user:
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- Date of Birth:*
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- Gender:*
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- What is your primary language?*
- Do you speak any other languages?*
- What other languages do you speak?*
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- Do you drive?*
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- Do you have another Emergency Contact?*
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- Desired Areas(s):
- Desired Availability:
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- Are you allergic to cats?*
- Are you able to work with a client who has cats?*
- Are you allergic to dogs?*
- Are you able to work with a client who has dogs?*
- Do you prefer to work with:*
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- Marital Status*
- Are you a resident of New York City?*
- Are you a resident of Yonkers?*
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- Are you a U.S. Citizen?*
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- HM - legally authorized to work
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- Have you had a final finding of patient abuse?*
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- Have you ever worked for this Employer before? Are you a re-hire?*
- Last Date of Employment
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- Hep B Vaccine - Please select from one of the following:*
- Influenza (flu) Vaccine - If you decline, you must wear a mask!*
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- Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired?*
- Or received SNAP Benefits for at least a 3-month period, but you are no longer receiving it?*
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- Are you a member of a family that received TANF assistance for at least the last 18 months before you were hired?*
- 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?*
- Are you a member of a family that received TANF assistance for any 9 months during the 18-month period before you were hired?*
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- 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?*
- Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days?*
- Have you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit?*
- Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance?*
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- Are you a Veteran of the US Armed Forces?*
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- Are you entitled to compensation for a service-connected disability?*
- Were you discharged from active duty within the last year?*
- Have you been arrested or convicted of a crime before?*
- Date of Conviction*
- Date of Release*
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- Were you referred to this employer by:*
- To the best of your knowledge, are you able to perform all duties required for this position with or without a reasonable accommodation?*
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- I am currently live in one of the below city/town:
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- I have working papers:
- I am currently enrolled in high school:
- I am currently enrolled in a High School Equivalency (HSE) program, or have obtained a high school diploma.
- I have a high school diploma, a GED or HSE diploma, satisfactorily completed a TASC exam, or I am enrolled in a TASC program.
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- I would like the Department of Labor to contact me by:
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- Are you currently experiencing any of these?*
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- 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.*
- Is your mailing address the same as where you live?*
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- Were you ever fingerprinted before at another Home Care Agency?*
- When did you have the fingerprints done?
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- Do you currently have any of the below symptoms?*
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- Would you like to sign up for direct deposit?*
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- Account Type*
- I wish to deposit:*
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- Do you have another bank to add?*
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- Account Type*
- I wish to deposit:*
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- Do you have another Former Employer to add?
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- Do you have a third Former Employer to add?
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- Should be Empty: