subject_line
Happy Health Services
vs101 221107
employment application Office: 702-257-9638
Last Name
*
First Name
*
Date Today
You have read the help work requirements.
(read help)
*
🛈
Yes are my requirements in (help) are complete
No, my requirements in (help) are not complete, but I have a client waiting or was instructed to complete the application.
Do we currently have a client waiting for you to complete your process
*
Yes
No
Name and phone of client waiting for service.
By sharing this information you indicate you have been authorized by the recipient to share their information on a unsecured submission.
*
Direct deposit
*
Direct deposit account setup is a requirement to be paid and remain on schedule
Pay Stubs Online
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I accept electronic viewing and printing of my pay stubs from my account as my method of receiving pay related information.
have you ever filed or collected on a workman's comp claim
*
Yes
No
give detail of workman's comp claim (when, how long, employer name, type of injury)
*
Do you have any physical conditions now that affect your ability to function at normal ability for lifting, walking and all other pca tasks required or have you had a medical condition in the past that may present itself working as a pca.
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Yes
No
give details of your increased injury risk
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Does your injury affect you physical ability performing PCA Services?
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Yes
No
How will your prior injuries affect your ability to perform PCA services?
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Have your ever worked for Happy Health Services or New World Associates Inc in the past
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Yes
No
first year worked mm/dd/yyyy
*
+
I agree to and understand terms of employment
(read help)
*
🛈
check to agree to all terms of employment
Personal Information
Address 1
*
unit# or none
*
City
*
State
*
Postal Code
*
Phone or Mobile
*
mobile
phone
000-000-0000
*
Mobile
*
mobile
none
000-000-0000
*
Phone
*
phone
none
000-000-0000
*
email (required to view pay account, taxes, and bank information with your own online account)
*
email
none
email
*
email verify
*
married status
*
single
married
married filing separately
gender
*
male
female
exemptions to claim
*
🛈
0
1
2
3
4
5
6
7
legal exempt
SS number (no dashes)
*
DOB mm/dd/yyyy
*
🛈
+
English language ability
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good
fair
understand only
NONE
other language
*
Spanish
Chinese
Psari
Japanese
Vietnamese
Tagalog
NONE
Position Applying For
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PCA / CNA
Office
LPN / RN
Salesperson
Other
kind of office work you are interested in
*
do you have a properly regestered and insured vehicle to drive to work sites
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Yes
No
auto make and model
*
license plate number
*
driver license number
*
Other methods of travel to clients you intend to use
*
Employment History
Last Employer
*
Address 1
*
unit# or none
*
City
*
State
*
Postal Code
*
Fax or Phone
*
fax
phone
unknown
000-000-0000
*
Fax
*
fax
unknown
000-000-0000
*
Phone
*
phone
unknown
000-000-0000
*
from mm/dd/yyyy
*
+
to mm/dd/yyyy
*
+
Position
*
hour rate 00.00
*
Reason for Leaving
*
Next To Last Employer
*
Address, city, zip
*
Fax or Phone
*
fax
phone
unknown
000-000-0000
*
Fax
*
fax
unknown
000-000-0000
*
Phone
*
phone
unknown
000-000-0000
*
from mm/dd/yyyy
*
+
to mm/dd/yyyy
*
+
Position
*
hour rate 00.00
*
Reason for Leaving
*
References
Name (first reference) Note: Inability to contact a reference could prevent employment
*
Company or Name and Title
*
Fax or Phone
*
fax
phone
unknown
000-000-0000
*
Fax
*
fax
unknown
000-000-0000
*
Phone
*
phone
unknown
000-000-0000
*
Name (second reference) Note: Inability to contact a reference could prevent employment
*
ompany or Name and Title
*
Fax or Phone
*
fax
phone
unknown
000-000-0000
*
Fax
*
fax
unknown
000-000-0000
*
Phone
*
phone
unknown
000-000-0000
*
Additional Skills
do you have any office software or computer skills
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Yes
No
typing speed per minute
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none
20
40
50+
Days Available
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
software use experience or write none
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Excel
Microsoft Word
Outlook
Act
network or IT skills
other office skills
other office skills
Attach Document
Signature of Applicant:
(Missing signature does not invalidate this document)
*
clear
The sender takes responsibility for the security of the computer used to send data, and understands the agency is not responsible for the security or content of information sent through the internet.
*
Agree