Nursing Registry Application

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BELLS NURSING REGISTRY APPLICATION

Application for Employment – please print clearly*(and fill out all fields)

I understand that neither this application nor any communication by a management representative is intended to create or does create a contract of employment offer or promise of employment. I acknowledge that if hired by the company, employment is on an At-Will basis. This means the company is free to terminate my employment at any time, with or without cause or advance notice. In accordance with State Law, and acceptance of employment is not a contract of employment for any specified time. Similarly, I am free to terminate my employment with the company at any time for any reason. This At-Will provision may be modified or waived only in a written agreement signed by and authorized representative of the company and me. I agree to conform to the rules and regulations of the company and I understand that the company has complete discretion to modify such rules and regulations at any time. Except that will modify its policy of employment At-Will.

We are an equal opportunity employer. Applicants are considered for positions without regard to religion, sex, race, national origin, age, disability, or any other consideration made unlawful by applicable federal, state or local laws.

Hidden

Please fill out both fields before clicking Next

Personal Information

Availability

Name*

Last Name First Name

SS#*

Email*

Enter your address*

Address Apt# City State Zip

Birth Date*

Gender*

Are you a US Citizen? If not are you authorized to Work in the US?*

Telephone (Home#)*

Telephone (Cell#)*

Cell Phone Provider*

Availability

I would like to work: (Check all that apply)
Part time (5-20 hrs/wk) || Full time (30-35 hrs/wk)

Monday

Availability

Not Available

Tuesday

Availability

Not Available

Wednesday

Availability

Not Available

Thursday

Availability

Not Available

Friday

Availability

Not Available

Saturday

Availability

Not Available

Sunday

Availability

Not Available

WORK EXPERIENCES

Please fill out at-least 3 work Experiences before clicking Next

Experience 1

Experience 2

Experience 3

Experience 4

Work Experience 1

Employer*

Work Performed*

Job Responsibilities*

Address ( Street, City, State )*

Telephone Number*

Job title*

Supervisor*

Reason for leaving*

Date Employed

From*

To*

Hourly Rate/ Salary

Starting*

Final*

Work Experience 2

Employer*

Work Performed*

Job Responsibilities*

Address ( Street, City, State )*

Telephone Number*

Job title*

Supervisor*

Reason for leaving*

Date Employed

From*

To*

Hourly Rate/ Salary

Starting*

Final*

Work Experience 3

Employer

Work Performed

Job Responsibilities

Address ( Street, City, State )

Telephone Number

Job title

Supervisor

Reason for leaving

Date Employed

From

Hourly Rate/ Salary

Starting

Final

Work Experience 4

Employer

Work Performed

Job Responsibilities

Address ( Street, City, State )

Telephone Number

Job title

Supervisor

Reason for leaving

Date Employed

From

Hourly Rate/ Salary

Starting

Final

REFERENCES

Please list the names of additional work-related references we may call. Individuals with no prior work experience may list school or volunteer related references.

REFERENCE 1

Name*

Company*

Relationship*

Telephone #*

REFERENCE 2

Name

Company

Relationship

Telephone #

REFERENCE 3

Name

Company

Relationship

Telephone #

APPLICANT CERTIFICATION

I understand and agree that if driving is a requirement of the job for which I am applying, my employment and/or continued employment is contingent on possessing a valid driver’s license and automobile insurance in an amount equal to the minimum required by the state where I reside.

I understand that the Company may now have, or may establish, a drug-free workplace or drug and/or alcohol testing program consistent with applicable federal, state and local law. If the Company has such a program and I am offered a conditional offer of employment, I understand that if pre-employment (post-offer) drug and/or alcohol test is positive, the employment offer may be withdrawn. I agree to work under the conditions requiring a drug-free workplace, consistent with applicable federal, state and local law. I also understand that all employees of the location, pursuant to the Company’s policy and federal, state and local law, may be subject to urinalysis and/or blood screening or other medically recognized and/or drug tests is a condition of continual employment and agree to undergo alcohol and drug testing consistent with the Company’s policies and applicable federal, state and local law.

If employment by the Company, I understand and agree that the company, to the extent permitted by federal, state and local law, may exercise its right; without prior warning or notice, to conduct investigations of properly (including, but not limited to files, lockers, desks, vehicles, and computers) and, in certain circumstances, my personal property.

I understand and agree that as a condition of employment and to the extent permitted by federal, state and local law, I may be required to sign a confidentiality, non-compete, and/or conflict of interest statement.

APPLICANT’S SIGNATURE (Please Print Full Name)*

Date*

New YORK State Confidentiality Law of HIV-Related Information

To company with the New York State Public Law article 27-F and the Department of Health regulations relative to the confidentiality of RN-related information, Bells Nurses Registry is required to inform you that;

During the course of the performance of your healthcare duties, it may become necessary, in order to appropriately render care to your patient, to disclose to you HIV information from confidential records which are protected by state law.

New York State law prohibits you from making any further disclosure of the information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law. Any unauthorized further disclosure in violations of state law may result in a fine of jail sentence or both. A general authorization for the release of medical or other information is NOT sufficient of further disclosure of HIV-related information.

Your signature confirms that you have read and understand the aforementioned brochure entitled “NEW YOURK State Confidentiality Law and HIV, Questions and Answers,”

If you have any questions, or need the above information clarified, please contact us.

APPLICANT’S SIGNATURE (Please Print Full Name)*

Date*

NOTIFICATION AND AOUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION

I understand that I may be subject to a background check, and hereby authorize Bells Nurses Registry & Employment Agency Inc, to investigate my background to determine any and information of concern as to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for my any damages on account of his/her furnishing said information.

Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records, criminal records, and credit history through an investigative or credit agency or bureau of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this for any future reports and updates that may be required.

I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired.

APPLICANT’S SIGNATURE (Please Print Full Name)*

Date*

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 State ZIP code

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.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5

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 jobs

Leave 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 $2,000

Multiply the number of other dependents by $500

Add the amounts above and enter the total here

Step 4 (optional): Other Adjustments

(a) Other Income
Other 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) Deductions
Deductions. 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

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)*

(This form is not valid unless you sign it.)

Date*
MM slash DD slash YYYY

Employee Emergency Contact Form
In the event of an emergency, please list names and telephone numbers of two Individuals you two would like us to contact:
Emergency Contact #1:
Name*

Address*
Home Address City State Zip

Work Phone #*
Cell Phone #*

Emergency Contact #2:
Name

Address
Home Address City State Zip

Work Phone #
Cell Phone #
Do you give us permission to transport you to the nearest medical facility should you incur serious illness or injury during normal work hours?*

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*
Is your primary language English?*
Or 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.

Direct Deposit Set-Up Form

Employee Information
Bank/Financial Instruction’s Name*

Bank’s routing # (It must have to be 9 digits)*

Account #*

Type of Account*

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)*

Employment Eligibility Verification (USCIS, Form I-9)

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0047 (Expires 10/31/2022)

► START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE:It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation

(Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
Name*
Last Name (Family Name) First Name (Given Name)
Middle Initial

Other Last Names Used (if any)

Address*
Street Number and Name Apt. Number City or Town State ZIP Code

Date of Birth*
MM slash DD slash YYYY

U.S. Social Security Number*

Employee's E-mail Address*

Employee's Telephone Number*

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form
I attest, under penalty of perjury, that I am (check one of the following boxes):*

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Alien Registration Number/USCIS Number):

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
Alien Registration Number

OR USCIS Number

OR
Form I-94 Admission Number

OR
Foreign Passport Number

Country of Issuance

Signature of Employee (Please Print Full Name)*

Today's Date*
MM slash DD slash YYYY

Preparer and/or Translator Certification*

I did not use a preparer or translator

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct
Signature of Preparer or Translator (Please Print Full Name)

Today's Date
MM slash DD slash YYYY

Name
Last Name (Family Name) First Name (Given Name)
Address
Street Number and Name City or Town State ZIP Code

Disclosure and Authorization

Bell’s Nurses Registry & Employment Agency may obtain information about information about you “consumer report” and for an “Investigative consumer report” which may include information about your character, general reputation, personal characteristics and ,if you are hired, throughout your employment. You have the right, upon, written request made within a reasonable time after receipt of your authoritative and, if you are hired, throughout your employment. You have the write request made within a reasonable time after receipt of this notice, to request disclosure report obtained with regard to applicants for employment is an investigation into your criminal history, education and/or employment history conducted by Accutane, Inc., 495 Highlands Bird, Suite 106 Coatesville, PA, 19320or by contacting us at 1-888-54-TRACE or another outside organization. The Scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement, agency, administrator, state or federal agency, institution, school or university (public or privet), information service bureau, employer, or insurance company to furnish any and all background information requested by accutrace, Inc. or another outside organization acting on behalf of Employer, and/or Employer it self. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original.

Minnesota and Oklahoma applicants or employees only: Please check this box if you like to would to receive a copy of a consumer report if one is obtained by the Company.

California applicants or employees or only: By singing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW, Please, check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.

New Jersey and Massachusetts applicants or employees only: If the company request an investigation report ( as defined by state law) from a consumer reporting agency, you have the right to have a copy of the report upon request.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency above directly.

State of Washington applicants or employees only: If the company an investigative consumer report ( as defined by state law ) from a consumer reporting agency, a you have the right to receive a complete and accurate disclosure of the nature and scope of the investigation by the Company. You also have the right to request a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

< Please Print Clearly >
Applicant’s Name*
First Last
Middle Initial

E-mail*

Maiden Name(s) Used

Nickname(s) Used

Signature (Please Print Full Name)*

Date*
MM slash DD slash YYYY

If applicable; I give permission to contact my current employer*
Date of Birth*
MM slash DD slash YYYY

Social Security No*

Driver’s License Number

State
Professional LICENSE/CERTIFICATE NUMBER

STATE
PROFESSION

SCHOOL/UNIVERSITY NAME

DEGREE/DIPLPMA TYPE

DATE RECEIVED
MM slash DD slash YYYY

Current Address*
Street Address City State Zip

No. of Years at Current Address*
Phone Number*
Previous Addresses within the past 7 Years ( Use back if additional space is needed)*
Street Address City State Zip

Nursing Registry Application

BELLS NURSING REGISTRY APPLICATION

Application for Employment – please print clearly*(and fill out all fields)

Availability

WORK EXPERIENCES

Work Experience 1

Date Employed

Hourly Rate/ Salary

Work Experience 2

Date Employed

Hourly Rate/ Salary

Work Experience 3

Date Employed

Hourly Rate/ Salary

Work Experience 4

Date Employed

Hourly Rate/ Salary

REFERENCES

REFERENCE 1

REFERENCE 2

REFERENCE 3

APPLICANT CERTIFICATION

New YORK State Confidentiality Law of HIV-Related Information

NOTIFICATION AND AOUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION

Employee’s Withholding Certificate (OMB No. 1545-0074 - 2020)

Form W-4 (Department of the Treasury Internal Revenue Service)

Step 1: Enter Personal Information

▶ Does your name match the name on your social security card?

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5

Step 2: Multiple Jobs or Spouse Works

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs

Step 3: Claim Dependents

Step 4 (optional): Other Adjustments

Step 5: Sign Here

Employee Emergency Contact Form

Emergency Contact #1:

Emergency Contact #2:

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

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

Direct Deposit Set-Up Form

Employee Information

Employee Information

Employment Eligibility Verification (USCIS, Form I-9)

Department of Homeland Security U.S. Citizenship and Immigration Services

Section 1. Employee Information and Attestation

Disclosure and Authorization

ACKNOWLEDGMENT AND AUTHORIZATION

< Please Print Clearly >

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

Department of Homeland Security
U.S. Citizenship and Immigration Services