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New Hire Form
1
Your Information
2
Education, Work History, and References
3
Direct Deposit Information
4
File Upload & Agreement
Your Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Are you a high school graduate or hold a GED?
*
Yes
No
Are you either a U.S. citizen or an alien authorized to work in the U.S.?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Please explain felony conviction
Position Desired
*
Start Date Available
*
Month
Day
Year
Are you related to or do you know anyone currently employed by Aloa Care Group?
*
Yes
No
Please explain your relationship to a current Aloa Care Group employee
*
Do you have a current CPR/AED/First Aid card?
*
Yes
No
CPR Expiration Date
Month
Day
Year
Education & Work History
Level of Study
*
Please check the following boxes for schooling you posses and provide details of each in the corresponding text areas below.
High School
Technical School
College/University
Post-Graduate Education
Other education, training, or special skills
High School Details
*
School Name
Graduated? Yes/No
Course of Study
Technical School Details
*
School Name
Graduated? Yes/No
Course of Study
College/University Details
*
School Name
Graduated? Yes/No
Course of Study
Post-Graduate Details
*
School Name
Graduated? Yes/No
Course of Study
Additional Education, Training, and Special Skills
*
Please add each of your additional education and training items as one line.
For Licensed Staff, Please Choose:
*
RN
LPN
MA
CNA
License Details
*
Please add each of your additional education and training items as one line.
License Number
State
Expiration Date
Has your license ever been suspended or revoked?
*
Yes
No
Please explain license suspension/revocation
*
Work Experience
Please list all previous employment, beginning with the most recent.
Most Recent Employer
*
Employer
Address
From/To
Most Recent Employer
*
Position Held
Reason For Leaving
Supervisors Name & Title
May We Contact?
Most Recent Employer
*
Description of Duties
Starting Compensation
Final Compensation
References
*
Identify two persons who know your work, beginning with the most recent.
Name
Phone Number
Email
Position or Title
Address
City, State, Zip
Years Known
Direct Deposit Information
Your Name
*
First
Middle Initial
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Social Security Number
*
Birth Date
*
Month
Day
Year
Number of Dependents
*
Email
*
Account Information
*
Routing Number
Account Number
Checking or Savings?
Section Break
Upload Your W-4
You may provide this document separately.
Drop files here or
Select files
Accepted file types: jpg, png, gif, pdf, Max. file size: 10 MB, Max. files: 10.
Upload Your Form I-9
You may provide this document separately.
Drop files here or
Select files
Accepted file types: jpg, png, gif, pdf, Max. file size: 10 MB, Max. files: 10.
Consent
*
I agree to the below authorization and acknowledgments statement.
I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge. I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.
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