Personal Information


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Personal Information

Physical Information


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Address Information


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Background History


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Other Information


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Driving License Information

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Emergency Contacts



Emergency Contacts

Hepatitis B Vaccine


Hepatitis B Vaccine Consent/Declination


Hepatitis B Vaccine

Work Information

Have you worked with Caring Professionals


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Armed Forces


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Personal References


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Personal References

New York Taxes


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Please use the IRS 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


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Federal Taxes

Dept. of Labor Statistics


Form 8850

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  • I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
  • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
  • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
  • I am at least age 18 but not age 40 or older and I am a member of a family that:
  • a. Received SNAP benefits (food stamps) for the past 6 months; or
  • b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
  • During the past year, I was convicted of a felony or released from prison for a felony.
  • I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
  • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
  • I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
  • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
  • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
  • I am at least age 18 but not age 40 or older and I am a member of a family that:
  • a. Received SNAP benefits (food stamps) for the past 6 months; or
  • b. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
  • During the past year, I was convicted of a felony or released from prison for a felony.
  • I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
  • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
  • Received TANF payments for at least the past 18 months; or
  • Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
  • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
  • Received TANF payments for at least the past 18 months; or
  • Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years; or
  • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

WOTC

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Were you referred to an employer by:

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New York Urban Youth Jobs Program

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  • I am pregnant or a parent of a child.
  • I am over 18 and do not have a high school diploma of GED/HSE diploma.
  • I am a member of a family that is receiving assistance from Temporary Assistance for Needy Families (TANF).
  • I am a member of a family that is receiving SNAP benefits (food stamps).
  • I am a member of a family that is receiving SSI benefits.
  • I am receiving a free of reduced-cost school lunch.
  • I have served in jail or prison, or am on probation or parole.
  • I am currently or was in foster care of the custody of the Office of Children and Family Services.
  • I am a veteran.
  • I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years.
  • I am the daughter or son of a parent who is collecting unemployment insurance.
  • I live in public housing or receive housing assistance such as a Section 8 voucher, or is homeless.
  • I am pregnant or a parent of a child.
  • I am over 18 and do not have a high school diploma of GED/HSE diploma.
  • I am a member of a family that is receiving assistance from Temporary Assistance for Needy Families (TANF).
  • I am a member of a family that is receiving SNAP benefits (food stamps).
  • I am a member of a family that is receiving SSI benefits.
  • I am receiving a free of reduced-cost school lunch.
  • I have served in jail or prison, or am on probation or parole.
  • I am currently or was in foster care of the custody of the Office of Children and Family Services.
  • I am a veteran.
  • I am the daughter or son of a parent who is currently in jail or prison, or has been within in the past two years.
  • I am the daughter or son of a parent who is collecting unemployment insurance.
  • I live in public housing or receive housing assistance such as a Section 8 voucher, or is homeless.

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Dept. of Labor Statistics

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

Days

Available Work Locations


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Skills


Patient Gender


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