Please complete and sign all forms in the PRE-EMPLOYMENT FORMS section.

Transcription

1 NATIONAL HOME HEALTH SERVICES EMPLOYMENT FORMS 5811 Dempster St Morton Grove, IL Phone: (847) Fax: (847) APPLICANT NAME POSITION APPLYING FOR DATE Please complete and sign all forms in the PRE-EMPLOYMENT FORMS section. Complete and sign forms in the FEDERAL/STATE FORMS section as instructed in each individual form. Submit the following additional documentation as applicable: Proof of Employment Eligibility (SS Card and visa or proof of citizenship) Licenses/Certifications CPR Certification Drivers License Proof of Auto Liability Insurance Resume (if available) Resent Criminal History Check From the Illinois State Police (if available) Results of a Recent Physical Examination (if available) Results of a Recent TB Exam (if available) Results of Vaccination (if available) Results of a Recent Drug Screening (if available) 5/2010

2 NATIONAL HOME HEALTH SERVICES PRE-EMPLOYMENT FORMS CONTENTS APPLICATION FOR EMPLOYMENT EMERGENCY CONTACT EMPLOYEE REFERENCE EMPLOYEE REFERENCE DRIVER CERTIFICATION BACKGROUND INVESTIGATION CONFIDENTIALITY AGREEMENT INSTRUCTIONS Print do not write. Answer each question. If a question does not apply, write N/A. Complete and sign all forms.

3 APPLICATION FOR EMPLOYMENT National Home Health Services, LLC is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, sex, religion, marital status, age, national origin, disability, veteran status, citizenship, or other protected status. PERSONAL INFROMATION LAST NAME FIRST NAME MIDDLE NAME DOB ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE NEW EMPLOYMENT POSITION DESIRED SALARY DESIRED DATE AVAILABLE HAVE YOU EVER APPLIED FOR EMPLOYMENT WITH US? YES NO If YES, month and year: Location: HOW WERE YOU REFERRED? Company Employee Employment Agency Career Website (specify): Other (specify): ADDITIONAL INFORMATION ARE YOU LEGALLY AUTHORIZED TO WORK IN THE U.S.? ARE YOU OVER 18 YEARS OF AGE? CAN YOU TRAVEL IF REQUIRED? YES NO YES NO ARE YOU ABLE TO WORK A NIGHT SHIFT, OVERTIME OR WEEKENDS IF NEEDED? YES NO YES NO HAVE YOU EVER BEEN CONVICTED OF A CRIME? YES NO (conviction will not necessarily disqualify applicant from the job applied for) HAVE YOU BEEN EXCLUDED FROM PARTICIPATING IN FEDERAL HEALTH CARE PROGRAMS? YES NO EDUCATION NAME AND LOCATION HIGH SCHOOL LAST YEAR COMPLETED MAJOR DEGREE EARNED COLLEGE / TECH SCHOOL ADVANCED DEGREE LICENSE VERIFICATION (Up to 3 professional licenses can be provided) DRIVER S LICENSE STATE EXPIRATION DATE HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED? TYPE OF LICENSE/CERTIFICATION YES NO RN LPN/LVN PT OT SLP MSW HHA/CNA Other (specify): LICENSE/CERTIFICATION # STATE EXPIRATION DATE HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED? TYPE OF LICENSE/CERTIFICATION YES NO RN LPN/LVN PT OT SLP MSW HHA/CNA Other (specify): LICENSE/CERTIFICATION # STATE EXPIRATION DATE HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED TYPE OF LICENSE/CERTIFICATION YES NO RN LPN/LVN PT OT SLP MSW HHA Other (specify): LICENSE/CERTIFICATION # STATE EXPIRATION DATE HAS YOUR LICENSE EVER BEEN REVOKED OR SUSPENDED YES NO NATIONAL HOME HEALTH SERVICES, LLC PAGE 1 OF 2 01/2009

4 EMPLOYMENT HISTORY (Starting with the most recent) COMPANY NAME EMPLOYMENT START AND END DATE ADDRESS PHONE SUPERVISOR S NAME PAY RATE AT START AND END OF EMPLOYMENT JOB TITLE REASON FOR LEAVING DESCRIPTION OF DUTIES COMPANY NAME EMPLOYMENT START AND END DATE ADDRESS PHONE SUPERVISOR S NAME PAY RATE AT START AND END OF EMPLOYMENT JOB TITLE REASON FOR LEAVING DESCRIPTION OF DUTIES COMPANY NAME EMPLOYMENT START AND END DATE ADDRESS PHONE SUPERVISOR S NAME PAY RATE AT START AND END OF EMPLOYMENT JOB TITLE REASON FOR LEAVING DESCRIPTION OF DUTIES COMPANY NAME EMPLOYMENT START AND END DATE ADDRESS PHONE SUPERVISOR S NAME PAY RATE AT START AND END OF EMPLOYMENT JOB TITLE REASON FOR LEAVING DESCRIPTION OF DUTIES PROVIDE ADDITIONAL INFORMATION THAT YOU THINK WOULD BE HELPFUL TO US IN EVALUATING YOUR APPLICATION I hereby authorize National Home Health Services to fully investigate my record and work qualifications and verify licensure/certification before or during my employment, and to facilitate such investigation. All employment is contingent upon successful completion of all background checks as well as physical examination and/or drug/alcohol screen. I so hereby authorize any persons having knowledge thereof to give such information to National Home Health Services upon request. I certify that all statements made by me on this application for employment and accompanying resume are true and correct. I acknowledge that misrepresentation, falsification or omission of facts may be grounds for rejection of my application; or if discovered after I am employed, such misrepresentation, falsification or omission may result in termination of my employment. I understand that if employed by the National Home Health Services, such employment is not for any definite period but is at will and may be terminated by either party at any period of time and without prior notice. I understand that any offer of employment is conditioned on my ability to establish eligibility under the Immigration Reform and Control Act of I certify that I have read the job description for the position for which I have applied. Printed Name Signature Date NATIONAL HOME HEALTH SERVICES, LLC PAGE 2 OF 2 01/2009

5 EMERGENCY CONTACT INFORMATION PERSONAL INFROMATION LAST NAME FIRST NAME MIDDLE NAME DOB EMERGENCY CONTACT #1 NAME: ADDRESS: HOME PHONE: BUSINESS PHONE: RELATIONSHIP: EMERGENCY CONTACT #2 NAME: ADDRESS: HOME PHONE: BUSINESS PHONE: RELATIONSHIP: NATIONAL HOME HEALTH SERVICES, LLC 10/2008

6 EMPLOYEE REFERENCE I,, have applied for employment with National Home Health Services, Name of Applicant LLC. I authorize them to collect any information concerning my qualifications and past performance. Further, I hereby release the company or person completing this form of any and all liability in supplying the requested information. Signature Date REFERENCE INFORMATION (Applicant list your reference in this section) NAME OF YOUR REFERENCE TITLE ADDRESS COMPANY POSITION OF YOUR REFERENCE PHONE FAX APPLICANT DO NOT WRITE BELOW THIS LINE EMPLOYMENT REFERENCE POSITION HELD IF NO, WHY NOT? WOULD YOU REHIRE? YES NO CHECK APPROPRIATE RATING: ABOVE AVERAGE AVERAGE BELOW AVERAGE Quality of Work Attendance / Dependability Cooperation / Attitude Common Sense Follows Directions (Verbal & Written) Leadership (if applicable) ADDITIONAL COMMENTS Signature Date 10/2009 NATIONAL HOME HEALTH SERVICES, LLC 5811 DEMPSTER ST MORTON GROVE IL TEL: (847) FAX: (847)

7 EMPLOYEE REFERENCE I,, have applied for employment with National Home Health Services, Name of Applicant LLC. I authorize them to collect any information concerning my qualifications and past performance. Further, I hereby release the company or person completing this form of any and all liability in supplying the requested information. Signature Date REFERENCE INFORMATION (Applicant list your reference in this section) NAME OF YOUR REFERENCE TITLE ADDRESS COMPANY POSITION OF YOUR REFERENCE PHONE FAX APPLICANT DO NOT WRITE BELOW THIS LINE EMPLOYMENT REFERENCE POSITION HELD IF NO, WHY NOT? WOULD YOU REHIRE? YES NO CHECK APPROPRIATE RATING: ABOVE AVERAGE AVERAGE BELOW AVERAGE Quality of Work Attendance / Dependability Cooperation / Attitude Common Sense Follows Directions (Verbal & Written) Leadership (if applicable) ADDITIONAL COMMENTS Signature Date 10/2009 NATIONAL HOME HEALTH SERVICES, LLC 5811 DEMPSTER ST MORTON GROVE IL TEL: (847) FAX: (847)

8 DRIVER CERTIFICATION Each employee who uses an automobile to conduct National Home Health Services business is required, as a condition of employment, to complete and sign this form in order to certify that s/he has: (1) a valid driver s license and (2) automobile insurance coverage at or above the minimum levels specified below. If you do not own an automobile but have a valid driver s license, you may be authorized to drive a rental vehicle or agency-owned vehicle on company business with prior approval from your supervisor. Please complete all information on this form to avoid being prohibited from driving on National Home Health Services business. PERSONAL INFROMATION LAST NAME FIRST NAME MIDDLE NAME DOB DRIVER S LICENSE INFORMATION I do not drive and I agree not to drive a rental or personal auto, even for brief periods, while on National Home Health Services business. (Skip to signature line If checking this box) I do not have a valid driver s license. I have a valid driver s license issued by the state of Drivers License #: Expiration Date: No Restrictions Restrictions: Specify AUTO LIABILITY INSURANCE COVERAGE I do not have a personal automobile I have auto liability insurance provided through policy number: Issued by, in the state of I certify that: (1) the above information is accurate and correct; (2) I will not drive on National Home Health Services business without meeting all of the requirements for license and liability coverage; (3) I will notify my immediate supervisor in the event that (a) my driver s license or (b) my liability insurance coverage is no longer in effect; (4) I will abide by the national Home Health Services policy on Driving on Company Business; and (5) I understand that falsification of information provided on this form is grounds for termination of my employment.. Signature Date NATIONAL HOME HEALTH SERVICES, LLC 11/2005

9 BACKGROUND INVESTIGATION NOTICE I authorize National Home Health Services to conduct investigations or to obtain an investigative report and analysis pertaining to employment and financial information, including retrieval of such from consumer reporting agencies, current and former employers, educational institutions and government sources and other sources, including but not limited to the information contained in the Application, references, or other information which may be provided by me, either in oral or written form. I release the Company, and its officers, directors, employees, subcontractors, investigators, agents, and assigns from any and all liability based upon their inquiry, as authorized above. I understand that, upon my written request, I will be told the nature and scope of the investigation requested and the name and address of the agency from whom the report was requested. I know that I may receive additional information concerning the report by contacting the consumer reporting agency. I further understand that I will be advised if an adverse employment action is going to be taken based in whole or in part on the report and that I will be given a copy of all public record information and the report before the adverse employment decision is made. This authorization shall be valid for the shorter of the period of six months from the date hereof or National Home Health Services final action on the Application, unless any employment relationship is established, in which case the authorization shall continue for the term of the employment. This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested. National Home Health Services will ensure that all background checks are held in compliance with all federal and state statutes. We guarantee that all information attained from the reference and background check process will only be used as part of the employment process and kept strictly confidential. Only appropriate personnel will have access to the information. Since background checks can be an expensive cost for the company, if an employee decides to resign their position within 30 days of hire or is terminated, they will be responsible for reimbursing National Home Health Services for the costs of the pre-employment screening. The employee will receive a deduction from their final paycheck to cover the company s expense for the pre-hire background checks. I acknowledge that I have received a summary of my rights under the Fair Credit Reporting Act. Printed Name Signature Date Social Security Number NATIONAL HOME HEALTH SERVICES, LLC 08/2005

10 CONFIDENTIALITY AGREEMENT I hereby acknowledge that in the course of my employment, National Home Health Services will make available to me confidential data and information. Such electronic verbal and/or written information may consist of, but is not limited to: patient health information; OASIS assessment information; lists of the names and addresses of patients/customers/employees; patients family histories; information relating to the organization s financial and/or contractual relations with customers; referral sources; administrative manuals; computer generated listings and documents; telephone conversations; directives and policies relating to the internal operations of the organization; and various documents containing information relating to the organization s recruiting, training, operating and soliciting functions. I understand that access to such information is only being made available to me in order that I may perform the duties for which I have been employed I specifically agree that: 1. During the course of my employment I will use such information only in connection with my employment and will not disclose the same to any other person or the general public, except those individuals who are directed to communicate such information at the appropriate time. 2. I will not copy and/or remove any such materials from the organization s premises except as needed to perform the duties for which I am employed. 3. I will ensure the security of such information throughout the day at the close of each day, and in preparation for transport. 4. Following my employment with the organization, I will immediately return to the organization all such materials and all other agency property in my possession. 5. Following my employment with the organization, I will not directly or indirectly: a. Disclose, solicit, use, or permit any other person to have access to the organization s materials; b. Cause any other individual to breach their confidentiality with the organization or solicit any employee to leave the organization s employ. c. Solicit or induce any client of the organization to terminate the relationships the client has with the organization. 6. I understand that any breach of confidentiality as stated herein will entitle the organization to injunctive relief, in addition to disciplinary action, up to and including dismissal. 7. I will abide by the provisions of the Confidentiality of Information employment policy. Printed Name Signature Date NATIONAL HOME HEALTH SERVICES, LLC 08/2005

11 NATIONAL HOME HEALTH SERVICES FEDERAL/STATE FORMS CONTENTS I-9 (EMPLOYMENT ELIGIBILITY VERIFICATION) W-4 IL-W-4 INSTRUCTIONS Print do not write. I-9: Complete Section 1 only, sign and date. W-4: Complete the bottom portion, questions 1 through 7. Sign and date. IL-W-4: Complete the bottom portion. Sign and date.

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14 Form W-4 (2015) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2015 expires February 16, See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Is age 65 or older, Is blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A You are single and have only one job; or B Enter 1 if: { You are married, have only one job, and your spouse does not work; or... B Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more than one job. (Entering -0- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above).. E F Enter 1 if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit... F (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $65,000 ($100,000 if married), enter 2 for each eligible child; then less 1 if you have two to four eligible children or less 2 if you have five or more eligible children. If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter 1 for each eligible child... G H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to that apply. avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee's Withholding Allowance Certificate Form W-4 Department of the Treasury Whether you are entitled to claim a certain number of allowances or exemption from withholding is Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Your first name and middle initial Last name OMB No Your social security number Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box. City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2015, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2015)

15 Illinois Withholding Allowance Worksheet General Information Complete this worksheet to figure your total withholding allowances. Everyone must complete Step 1. Complete Step 2 if Adjustments Worksheet for federal Form W-4. If you have more than one job or your spouse works, you should figure the total number of allowances you are entitled to claim. Your withholding usually will be more accurate if you claim all of your allowances on the Form IL-W-4 for the highest-paying job and claim zero on all of your other IL-W-4 forms. You may reduce the number of allowances or request that your employer withhold an additional amount from your pay, which may help avoid having too little tax withheld. Step 1: Figure your basic personal allowances (including allowances for dependents) Check all that apply: No one else can claim me as a dependent. I can claim my spouse as a dependent. 1 Write the total number of boxes you checked. 1 2 Write the number of dependents (other than you or your spouse) you will claim on your tax return. 2 3 you are entitled. 3 4 number of basic personal allowances or have an additional amount withheld. Write the total number of basic personal allowances you elect to claim on Line 4 and on Form IL-W-4, Line 1. Step 2: Figure your additional allowances Check all that apply: I am 65 or older. My spouse is 65 or older. I am legally blind. My spouse is legally blind. 4 5 Write the total number of boxes you checked. 5 6 for federal Form W-4 plus any additional Illinois subtractions or deductions you are entitled. 9 number of additional allowances or have an additional amount withheld. Write the total number of additional allowances you elect to claim on Line 9 and on Form IL-W-4, Line amount withheld from your pay. On Line 3 of Form IL-W-4, write the additional amount you want your employer to withhold. Cut here and give the certificate to your employer. Keep the top portion for your records. Illinois Department of Revenue IL-W-4 Employee s Illinois Withholding Allowance Certificate - - Social Security number Name Street address City State ZIP Check the box if you are exempt from federal and Illinois IL-W-4 (R-12/12) of this information is required. Failure to provide information may result in this form not being processed and may result in a penalty. 1 Write the total number of basic allowances that you are claiming (Step 1, Line 4, of the worksheet). 1 2 Write the total number of additional allowances that you are claiming (Step 2, Line 9, of the worksheet). 2 3 Write the additional amount you want withheld (deducted) from each pay. 3 I certify that I am entitled to the number of withholding allowances claimed on this certificate. Employer: Keep this certificate with your records. If you have referred the employee s federal certificate to the IRS and the IRS has notified you to disregard it, you may also be required to disregard this certificate. Even if you are not required to refer the employee s federal certificate to