Homecare Application "*" indicates required fields Step 1 of 13 7% BELLS HOME CARE, INC. EMPLOYMENT APPLICATION Please Print clearly. This application must be completed and all questions regarding your training and work experience answered. All information on this application is confidential. BELLS HOME CARE, INC. will not contact your present employer without your consent. Name* First Last Middle Initial Other Name:(If applicable) Social Security #* Current Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Length of time of this address*Previous Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Length of time of this address*Home PhoneCell Phone*US Citizen*SelectYesNoIf no, immigrant ID/Card* Position Applied for*SelectAdmin.RNLPNHHAPCAPT/OT/RTMSWClericalOtherMinimum Salary Requirement:Date Available MM slash DD slash YYYY EDUCATION/SCHOOLS ATTENDED AIDE TRAINING PROGRAM HIGH SCHOOL COLLEGE GRADUATE SCHOOL BUSINESS SCHOOL NAME OF SCHOOL* DID YOU GRADUATE?*SelectYesNoCOURSE OR MAJOR* DIPLOMA OR DEGREE*SelectDIPLOMADEGREEAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME OF SCHOOL DID YOU GRADUATE?SelectYesNoCOURSE OR MAJOR DIPLOMA OR DEGREESelectDIPLOMADEGREEAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME OF SCHOOL DID YOU GRADUATE?SelectYesNoCOURSE OR MAJOR DIPLOMA OR DEGREESelectDIPLOMADEGREEAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME OF SCHOOL DID YOU GRADUATE?SelectYesNoCOURSE OR MAJOR DIPLOMA OR DEGREESelectDIPLOMADEGREEAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME OF SCHOOL DID YOU GRADUATE?SelectYesNoCOURSE OR MAJOR DIPLOMA OR DEGREESelectDIPLOMADEGREEAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code WORK HISTORY (PROVIDE 10 YEARS OF WORK HISTORY) Employers 1 Employers 2 Employers 3 Employers 4 Employers 5 Employers 6 Employers 7 Name* Phone #*From* MM slash DD slash YYYY To* MM slash DD slash YYYY Job Title* Supervisor’s Name* Salary*Reason of Leaving* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name Phone #From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title Supervisor’s Name SalaryReason of Leaving Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name Phone #From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title Supervisor’s Name SalaryReason of Leaving Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name Phone #From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title Supervisor’s Name SalaryReason of Leaving Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name Phone #From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title Supervisor’s Name SalaryReason of Leaving Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name Phone #From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title Supervisor’s Name SalaryReason of Leaving Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name Phone #From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title Supervisor’s Name SalaryReason of Leaving Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EMPLOYMENT APPLICATIONHave you ever been bonded?*SelectYesNoIf Yes, by Whom* Have you ever been refused a bond?*SelectYesNoIf Yes, by Whom* Have you ever been convicted of a crime?*SelectYesNoIf Yes, Explain* Professional Licenses 1 Profession Lic.No Exp. Date MM slash DD slash YYYY Verification Professional Licenses 2 Profession Lic.No Exp. Date MM slash DD slash YYYY Verification Para-Professional Certification 1SelectHHAPCASchool/Training Program Verification Para-Professional Certification 2SelectHHAPCASchool/Training Program Verification The information listed in my application is completed and true. I understand that if employed, false statements on this application are cause for dismissal. I will comply with all of the agency’s rules and regulations regarding my employment. BELLS HOME CARE, INC. may request information regarding my background which will include work and personal references. Signature (Please Print Full Name)* Date* MM slash DD slash YYYY BELLS HOME CARE, INC. does not discriminate because of sex, age, physical handicap, race, creed or national origin. The agency is an equal opportunity employer.ADDITIONAL REFERENCES REFERENCE 1 REFERENCE 2 REFERENCE 3 REFERENCE 4 NAME* RELATIONSHIP* ADDRESS* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME RELATIONSHIP ADDRESS Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME RELATIONSHIP ADDRESS Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NAME RELATIONSHIP ADDRESS Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code BELLS HOME CARE, INC. REFERENCE REQUEST To* Agency* Title* Name of Applicant* Position Applied for* Release of information: I hereby release from all liability the company, institution or person named above and authorize them to release all information regarding my employment with them. Signature of Applicant (Please Print Full Name)* Date* MM slash DD slash YYYY BELLS HOME CARE, INC. REFERENCE REQUEST To* Agency* Title* Name of Applicant* Position Applied for* Release of information: I hereby release from all liability the company, institution or person named above and authorize them to release all information regarding my employment with them. Signature of Applicant (Please Print Full Name)* Date* MM slash DD slash YYYY BELLS HOME CARE, INC. VERBAL REFERENCE Name of Applicant* Position Applied for* Release of information: I hereby release from all liability the company, institution or person named above and authorize them to release all information regarding my employment with them. Signature of Applicant (Please Print Full Name)* Date* MM slash DD slash YYYY BELLS HOME CARE, INC. HEPATITIS B VACCINE PROGRAM I do not wish to given the Hepatitis B Vaccine at that time. I am aware that I may request to be provided the vaccine at a later date during my employment with the agency. I have already received the Hepatitis B Vaccine series. Signature (Please Print Full Name) Date MM slash DD slash YYYY I am requesting to receive the Hepatitis B Vaccine. (complete consent below) HEPATITIS B VACCINATION CONSENT Full Name I, _______________ , have been provided with information on the Hepatitis B Vaccine and have been evaluated by an agency health professional. I have had the opportunity to ask questions about the benefits and risks of Hepatitis B Vaccination. I also understand that there is no guarantee that I will become immune and that there is a possibility that I will experience an adverse side effect from the vaccine. Choose one from the following optionsSelectI am NOT allergic to yeast or yeast productsI am NOT currently immunosuppressed, neither by disease or medicationFor women: I have been advised that studies have not been conducted to determine the effect of the vaccine on a developing fetus. Therefore, the safety of the Hepatitis B Vaccine relating to the developing fetus is currently unknown.Employee Signature (Please Print Full Name) Date MM slash DD slash YYYY Witness Signature (Please Print Full Name) Date MM slash DD slash YYYY BELLS HOME CARE, INC. EMPLOYEE HEALTH ASSESSMENT Name* Marital Status*SelectMSWDSex*SelectMaleFemaleSS#* Title* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact* Relationship* Emergency Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone No.* INDICATE ILLNESS EXPERIENCED BY YOU OR FAMILY CONDITION DIABETIS*SelectYESNOKIDNEY DISEASE*SelectYESNOHEART DISEASE*SelectYESNOHIGH BLOOD PRESSURE*SelectYESNOARTHRITIS*SelectYESNOTUBERCULOSIS*SelectYESNOMENTAL ILLNESS*SelectYESNOEPILEPSY/CONVULSIONS*SelectYESNOCANCER*SelectYESNOMIGRANE HEADACHES*SelectYESNOFAINTING OR DIZZINESS*SelectYESNOWEIGHT GAIN/LOSS 15+ LBS. OR MORE*SelectYESNOCHANGE IN ENERGY LEVEL*SelectYESNOFREQUENT COUGH*SelectYESNOBLOOD IN SPUTUM*SelectYESNOSHORTNESS OF BREATH*SelectYESNOCHEST PAIN/PRESSURE IN CHEST*SelectYESNOSWELLING IN LEGS AND FEET*SelectYESNOPAIN IN CALF WHEN WALKING*SelectYESNOCHANGE IN BOWEL HABITS*SelectYESNOBACK PAIN*SelectYESNOHIGH BLOOD PRESSURE*SelectYESNOPAIN WHEN URINATING/ BLOOD IN*SelectYESNOINFECTIOUS DISEASE*SelectYESNOINCREASED THIRST*SelectYESNOPERSISTANT SORES OR LUMPS*SelectYESNO TB SCREEN Have you experienced the following symptoms Chest Pain*SelectYESNOLingering Cough*SelectYESNOLoss of Energy*SelectYESNOWeight Loss +15 lbs in past year*SelectYESNOBlood in Sputum*SelectYESNOIncreased Sweating at Night*SelectYESNODo you smoke?*SelectYesNoif yes how much?* Do you drink alcoholic beverages?*SelectYesNoif yes how much?* Do you take depressant, stimulant, narcotic drugs that alter your behavior?*SelectYesNoDo you take prescription medications?*SelectYesNoif yes, which medications?* Name of your Physician* Telephone No.*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I have read the above and declare that I am free from health impairment which is of potential risk to the patient or which might interfere with the performance of mu duties, including the habituation or addiction to depressants, simulants, narcotics, alcohol or other substances that may alter my behavior. Signature (Please Print Full Name)* Date* MM slash DD slash YYYY Declination of Influenza Vaccination (Optional) For Health Care Personal. Employee’s Name Employee’s ID# 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 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 the facility. If I become infected with influenza, I can spread severe illness to others even when my symptoms are mils 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. Because I have refused vaccination 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 this document in its entirety and fully understand it. Despite these facts, I have decided to decline the influenza vaccine by my signature below. I realize that I may re-address this issue at any time and accept vaccination in the future. Signature (Please Print Full Name) Date MM slash DD slash YYYY Witness (Please Print Full Name) Date MM slash DD slash YYYY DOH CHRC 102 (1/07) NYS Department of Health ACCKNOWLEDGEMENT AND CONSENT FORM FOR FINGERPRINTING AND DISCLOSURE OF CRIMINAL HISTORY RECORD INFORMATION THIS FORM IS TO BE REATINED BY THE AGENCY- DO NOT FORWARD TO DOH CHRC UNIT. chrcr@health.state.ny.us The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the executive Law. SECTION 1 – SUJECT INDIVIDUAL INFORMATION Name* First Last M.I. Date of Birth* MM slash DD slash YYYY Mother’s Maiden Name* Allas: AKA* Mailing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code SECTION 2 – ATTESTATION I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI). I acknowledgement and consent to having my fingerprints taken for the purpose of a criminal history check by the DCJS and FBI. I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary to be provided to the agency to which I applied for a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I have a criminal history, as maintained by DCJS or the FBI, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. I have been advised that by law, DOH is authorized and may be required to provide the results of the criminal history record check through a criminal history record summary to the agency. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, ruled and regulations and shall only be disclosed to persons authorized by law. I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place. I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI. I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information. My current mailing or home address is indicated in Section 1 of this form. I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, if any, from the DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and the fingerprints to be submitted are my own (not applicable for Expected Review submitted pursuant to CHRC Form 104). I certify to the best of my knowledge and belief that I (check as appropriate)* Have been convicted of a crime in New York State or any other jurisdiction Have not been convicted of a crime in New York State or any other jurisdiction Do have a final finding of patient or resident abuse Do not have a final finding of patient or resident abuse If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)Applicant Signature (Please Print Full Name)* Date* MM slash DD slash YYYY Signature of Parent or Legal guardian (if subject individual is under 18 years age) Date MM slash DD slash YYYY Employee’s Withholding Certificate (OMB No. 1545-0074 - 2020) ▶ Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. ▶ Give Form W-4 to your employer. ▶ Your withholding is subject to review by the IRS. Form W-4 (Department of the Treasury Internal Revenue Service) Step 1: Enter Personal Information (a) Name* First name and middle initial Last name (b) Social security number* ▶ Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov. Address* Address City or town AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP code (c) Marital Status* Single or Married filing separately Married filing jointly (or Qualifying widow(er)) Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.) See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy Step 2: Multiple Jobs or Spouse Works Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Do only one of the following. (a) ) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or (b) ) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding;or (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator. Complete Steps 3–4(b) on Form W-4 for only ONE of these jobsLeave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)Step 3: Claim Dependents If your income will be $200,000 or less ($400,000 or less if married filing jointly):Multiply the number of qualifying children under age 17 by $2,000Multiply the number of other dependents by $500Add the amounts above and enter the total hereStep 4 (optional): Other Adjustments(a) Other IncomeOther income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income(b) DeductionsDeductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here(c) Extra withholdingExtra withholding.Enter any additional tax you want withheld each pay period Step 5: Sign Here Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete Employee’s signature (Please Print Full Name)* Date* MM slash DD slash YYYY Direct Deposit Set-Up Form Employee InformationBank/Financial Instruction’s Name* Bank’s routing # (It must have to be 9 digits)* Account #* Type of Account*CheckingSavingsOther Employee Information I authorize Bells Nurses Registry & Employment Agency, INC to automatically deposit my payroll into my listed above, this includes authorization to correct any entries made in error. This authorization will remain in effect until I give written notice to cancel it. Date Processed:* MM slash DD slash YYYY Signature (Please Print Full Name)* Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law Notice for Employees of Temporary Help Firms Employee Acknowledgement On this day, I received notice of my pay rate, overtime rate (if eligible), allowances, and designated payday. I told my employer what my primary language is.Position*SelectHHARNIs your primary language English?*SelectYesNoOr my primary language is ...* I have been given this pay notice in English only, because my primary language is English.Print Employee Name* Applicant/Employee Signature (Please Print Full Name)* Date* MM slash DD slash YYYY Preparer Name and Title The employee must receive a signed copy of this form. The employer must keep the original for 6 years. Please note: It is unlawful for an employee to be paid less than an employee of the opposite sex for equal work. Employers also may not prohibit employees from discussing wages with their co-workers. Availability I would like to work: (Check all that apply) Part time (5-20 hrs/wk) || Full time (30-35 hrs/wk) MondaySelect Time7:00 am - 7:00 pm7:00 pm - 7:00 amLive-inSelectYesNoAvailability Not Available TuesdaySelect Time7:00 am - 7:00 pm7:00 pm - 7:00 amLive-inSelectYesNoAvailability Not Available WednesdaySelect Time7:00 am - 7:00 pm7:00 pm - 7:00 amLive-inSelectYesNoAvailability Not Available ThursdaySelect Time7:00 am - 7:00 pm7:00 pm - 7:00 amLive-inSelectYesNoAvailability Not Available FridaySelect Time7:00 am - 7:00 pm7:00 pm - 7:00 amLive-inSelectYesNoAvailability Not Available SaturdaySelect Time7:00 am - 7:00 pm7:00 pm - 7:00 amLive-inSelectYesNoAvailability Not Available SundaySelect Time7:00 am - 7:00 pm7:00 pm - 7:00 amLive-inSelectYesNoAvailability Not Available