Citizenship Status

Alien Registration Number/USCIS Number:

USCIS Number:

Emp. Authorization ID Expiration Date

ID Type - Select ALL that Apply

State ID Number

State ID Expiration Date

State Benefit ID Number

Permanent Resident Card ID Number

Perm. Resident Card ID Expiration Date

Employment Authorization Card ID

Foreign Passport with I-551 ID Number

Foreign Passport I-551 ID Expiration Date

US Passport ID Number

US Passport Expiration Date

US Passport Card ID Number

US Passport Card Expiration Date

Date of Hire:

Starting Date:

Title:

Salary:

HR Representative First Name

HR Representative Last Name

HR Representative Signature

HHA/PCA Application for Employment

First Name

Middle Initial

Last Name

Maiden Name

Mother's Maiden Name

Other Names Used (Alias)

Street Address:

Apartment/Suite #:

City:

State:

Zip:

County:

Mobile Phone Number:

Secondary Phone Number:

Email Address:

example@example.com

Date of Birth:

Country of Birth:

Race:

Gender:

Social Security #:

Eye Color

Hair Color

Height

Weight

Have you ever worked or applied with us before?

Enter the last date of employment:

What is your primary language?

Do you speak any other languages?

What other languages do you speak?

Position(s) Applying For:

Emergency Contact Name

Phone Number:

Relationship

Address

Were you referred by anyone?

Referral Name:

Phone Number:

Hm - Emergency Relationship

How did you hear about us?

Tax Marital Status

Are you a resident of New York City?

Are you a resident of Yonkers?

Total number of children UNDER age 17

Total number of children OVER age 17

HM Federal Exemptions

Are you a U.S. Citizen?

Are you a lawful permanent resident?

Are you an alien authorized to work?

**Sorry, we cannot accept your application at this time. Please start your application over again**

Have you ever been convicted of a crime?

Have you had a final finding of patient or resident abuse?

If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)

At this time, we cannot process your application.

Reference Full Name:

Reference Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

List below your previous employer(s), starting with the last one.

Company Name

Position

Supervisor's Name

Phone

Address

Reason for Leaving

Start Date

End Date

Do you have another Former Employer to add?

Name of Company

Position

Phone

Address

Reason for Leaving

Start Date

End Date

Do you have a third Former Employer to add?

Name Of Third Employer

Position

Phone

Address

Reason for Leaving

Start Date

End Date

Would you like to enroll in direct deposit?

Bank Name:

Account Number:

Routing Number:

Type of account:

I would like to:

Enter the % to deposit:

Enter the $ amount to deposit:

Do you have another account to add?

Bank Name:

Account Number:

Routing Number:

Type of account:

I would like to:

Enter the % to deposit:

Enter the $ amount to deposit:

Hepatitis B Vaccine - Please select from one of the following:

Influenza / Flu:

I have been advised that I should receive the influenza vaccine to protect myself and the patients I serve. I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement explaining the vaccine and the disease it prevents. I have had the opportunity to discuss the statement and have my questions answered by a healthcare provider. I am aware of the following facts:

Influenza is a serious respiratory disease that kills thousands in the United States each year.
Influenza vaccination is recommended for me and all other healthcare personnel to protect this facility’s patients from influenza, its complications, and death.
If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or non-existent.
I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t, my immunity declines over time. This is why vaccination against influenza is recommended each year.
I understand that I cannot get influenza from the influenza vaccine.
The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including all patients in this healthcare facility, coworkers, my family and my community.
If I choose not to get vaccinated against influenza, I will be required to wear surgical or procedure masks in areas where patients or residents may be present during the influenza season.

I acknowledge that I have read the above in its entirety and fully understand it.

Do you have any of the following symptoms?

1. Chronic Cough lasting more than 3 weeks
2. Coughing up blood
3.Unexplained Weight Loss
4. Fever, chills or night sweats for no known reason
5. Persistent Shortness of Breath
6. Unexplained fatigue
7. Chest Pains

No Symptoms

Select the Symptoms

Rows	Yes	No
1. Chronic Cough lasting more than 3 weeks
2. Coughing up blood
3.Unexplained Weight Loss
4. Fever, chills or night sweats for no known reason
5. Persistent Shortness of Breath
6. Unexplained fatigue
7. Chest Pains

Have you had contact with anyone with active tuberculosis disease in the past year?

Are you currently undergoing immunosuppression including: HIV, organ transplant treatment with TNF-alpha antagonists, chronic steroids, or other immunosuppressive agents?

Have you stayed in any country other than Australia, Canada, New Zealand, the US or Northern/Western Europe for greater than 1 month?

Have you had close contact with a person with active TB disease?

Have you been treated for a latent TB infection?

Have you had a prior diagnosis of active TB or Latent TB, or had a positive TB skin or blood test?

Have you ever been treated with medication for TB or a positive TB test?

Please explain:

I am 16 or 17 years old and have the permission of my parent of guardian to submit this application.

Parent or Guardian Name:

Parent or Guardian Phone Number:

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

a. I am currently unemployed.
b. I was unemployed prior to completing this application.
c. I do not have enough paid work.
d. The work I have does not make use of my skills and training.

Yes No

Are any of the following true?
I have a high school diploma.
I have a General Education Development diploma (GED).
I have High School Equivalency (HSE) diploma.
I have satisfactorily completed a Test for Assessing Secondary Completion (TASC) exam.
I am enrolled in a Treatment Accountability for Safer Communities (TASC) program.

Yes No

I would like the Department of Labor to contact me by:

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

And City, State where benefits were received

Are you a Veteran of the US Armed Forces?

Are you a member of a family that received SNAP benefits for at least 3 months during the 15 months?

Name of primary recipient:

And City, State where benefits were received

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

Were you discharged from active duty within the last year?

Are you a veteran unemployed for a combined period of at least 6 months before you were hired?

HM - No to veteran

Are you a member of a family that received SNAP (Food Stamps) benefits during the past 6 months?

Did you get SNAP for 3 out of the past 5 months but are no longer getting them?

Name of Primary Recipient of Food Stamps (SNAP)

And City, State where benefits were received

Are you a member of a family that received TANF (Cash Benefits) assistance for at least the last 18 months before you were hired?

Name of Primary Recipient of Cash Benefits (TANF):

And City, State where benefits are received:

Did your family stop being eligible for TANF assistance within 2 years before being hired because you reached the maximum time those benefits can be received?

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

Were you ever convicted of a felony

Date of Conviction:

Date of Release:

What type of crime was it:

Were you referred by a Network under the Ticket to Work program?

Were you referred by a Vocational Rehabilitation Agency approved by a State?

Were you referred by the Department of Veteran Affairs?

I have reviewed the Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law for Home Care Aides Wage Parity and Other Jobs

By clicking the submit button, I agree to terms & conditions.

Applicant Signature

Do you have any objection to I9 verification?

Rows	Name of School	Course or Major	Graduated?	Date of Completion
High School
College/University
Aide Training Program

For Office Use Only

HHA/PCA Application for Employment

Personal Information

W4 & I9

Legal & Background Checks

References

Employment History

Pay - Direct Deposit

Health Questionnaire

New York Urban Youth Jobs Program

Government Assistance

Veteran Details

SNAP (Food Stamps)

TANF (Cash Benefits)

Vocational Rehab

Employee Status & Referrals

Policies

Benefits & Compensation

General Questions

Benefits