Avondale HHA Application - NYC Recruiting

HHA/PCA Application for Employment
For Office Use Only
Citizenship Status
Alien Registration Number/USCIS Number:
USCIS Number:
Emp. Authorization ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
ID Type - Select ALL that Apply
{nycId} ID Number
{nycId} ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
ID Expiration Date as text
List B expiration date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State Benefit ID Number
Permanent Resident Card ID Number
Perm. Resident Card ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Employment Authorization Card ID
Foreign Passport with I-551 ID Number
Foreign Passport I-551 ID Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
US Passport ID Number
US Passport Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
US Passport Card ID Number
US Passport Card Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I9 Hire Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Base Rate
Supplemental Wages
Overtime Rate
Send Payrate PDF to user:
Personal Information
First Name
Middle Name
Last Name
Alias/AKA Name
Maiden Name
Street Address:
Apartment/Suite #:
Hidden spacer
City:
State:
Zip:
Mobile Phone Number:
Home Phone Number:
Email Address :
example@example.com
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Social Security #:
Gender:
Eye Color:
Hair Color:
Weight:
in pounds
Height
What is your primary language?
Do you speak any other languages?
What other languages do you speak?
Country of Birth:
Race:
Do you drive?
Emergency Contact Name:
First/Last
Phone Number:
Relationship:
Do you have another Emergency Contact?
Emergency Contact Name:
First/Last
Phone Number:
Relationship:
Do you have another Emergency Contact?
Emergency Contact Name:
First/Last
Phone Number:
Relationship:
How did you hear about Avondale Home Care?
Availability and Experience
How many years experience do you have as a HHA/PCA?
When can you start if hired?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you able to work as a live-in HHA?
Do you have experience working with:
Hours available per week:

Desired work schedule:

Rows	Start Time	End Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Areas you can work:
References and Referrals

Provide THREE references. At least one must be professional:

Rows	Name	Relationship	Phone Number
Reference 1
Reference 2
Reference 3

Refer some friends that an join:

Rows	Name	Relationship	Phone Number
Referral 1
Referral 2
Referral 3

W4 & I9
Tax Marital Status
oldMarital Status
Are you a resident of New York City?
Are you a resident of Yonkers?
Total number of children UNDER age 17
Other Dependents
Are you a U.S. Citizen?
Are you a lawful permanent resident?
Are you an alien authorized to work?
If not, give Visa # and expiration:
HM - legally authorized to work
**Sorry, we cannot accept your application at this time. Please start your application over again**
Have you been convicted of a crime?
Have you had a final finding of patient abuse?
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?
Last Date of Employment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Health Questionnaire
Hep B Vaccine - Please select from one of the following:
Date Vaccine Received:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you received the Influenza (flu) Vaccine?
Influenza (flu) Vaccine Declination:

Other
Benefits & Compensation
Would you like to sign up for direct deposit?
Bank Name
Bank Account Number
Bank Routing Number
Account Type
I wish to deposit:
Dollar amount
Do you have another bank to add?
Bank Name
Bank Account Number
Bank Routing Number
Account Type
I wish to deposit:
Dollar amount
Government Assistance
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?
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?
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?
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?
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?
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:

Other
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:
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.
Parent or Guardian Name:
Parent or Guardian Phone Number:
I would like the Department of Labor to contact me by:
Employee Status & Referrals
Are you a Veteran of the US Armed Forces?
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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Date of Release

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Type of Felony:
Please explain:
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?
Live in Collect
Signature
Please review the following documents:
By clicking the submit button, I agree to terms & conditions.
Applicant Signature
Remote Inspected
Remote Inspected Date
Remote Inspected By First Name
Remote Inspected By Last Name
Remote Inspected By First Name
Remote Inspected By Last Name:
Remote Inspected Date:

Rows	No	Yes
Weakness
Unexplained Fatigue for more than 3 weeks
Lack of Appetite
Unexplained Weight Loss
Low Grade Fever
Unexplained Fever, Chills, or Drenching Night Sweats
Persistent Shortness of Breath
Persistent cough for more than 3 weeks
Blood streaked sputum
Clear, Yellow, or Dark Sputum
Coughing Up Blood
Chest Pain
Have you ever been diagnosed with active TB disease?
Have you been treated with medication for TB or for a positive TB test?
Have you ever been diagnosed with latent TB infection or had a positive skin test or a positive blood test for TB?
Have you ever lived in a country with a high TB rate?
Is your immune system compromised due to a virus or medication?
Have you recently had close contact with someone who has had TB disease?

HHA/PCA Application for Employment

For Office Use Only

Personal Information

Availability and Experience

References and Referrals

W4 & I9

Health Questionnaire

Benefits & Compensation

Government Assistance

New York Urban Youth Jobs Program

Employee Status & Referrals

Signature

Education & Employment History