Personal Information

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Personal Information

Physical Information


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Address Information



Address Information

Other Information


No

No

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Driving License Information

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Emergency Contacts



Emergency Contacts

Health Assessment



Health Assessment

TB Screening/Risk Assessment


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  • Productive cough for more than 3 weeks.
  • Coughing up blood.
  • Unexplained weight loss.
  • Fever, chills, or drenching night sweats for no known reason.
  • Persistent shortness of breath.
  • Unexplained fatigue for more than 3 weeks.
  • Chest pain.

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TB Screening/Risk Assessment

Work Information

Have you worked with Rockaway Home Care


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Personal References


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Personal References

Employment History


Work #1

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Work #2

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Employment History

General


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Certification


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New York Taxes


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Please use the NYS worksheet HERE to find out your allowances

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Use the fields below to have additional withholding per pay period under special agreement with your employer.

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New York Taxes

Federal Taxes


Step 1: Personal Information

How will you file your Federal Taxes?


Step 2: Multiple Jobs or Spouse Works


Step 3: Claim Dependent and Other Credits

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Step 4: Other Adjustments (optional)

Other income (not from jobs).

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Deductions.

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Extra withholding.

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Federal Taxes

I-9


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2.
3.
4.

I-9

Direct Deposit


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Enter your account information to get paid with direct deposit.

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Accepted Formats : (pdf, png, jpg, jpeg)

Days


Days
From Time
To Time
Live In
Sunday
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Monday
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Tuesday
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Wednesday
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Thursday
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Friday
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Saturday
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Days

Available Work Locations


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Skills


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