85 Bartlett Street, Brooklyn, NY 11206 Fax: (718) 782-1538 www.whiteglovecare.com
Page 1 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE COMMUNITY CARE, INC. Community Care Application Registered Nurse/Licensed Practical Nurse Thank you for your interest in White Glove Community Care. We are committed to make this home health experience a rewarding one. The following documentation must be completed and submitted, prior to your first assignment. We therefore request that you, sign and return all documents in a timely manner. An online Home Health test will be scheduled upon receipt of your completed application. The following documentation should be submitted to our main office at 85 Bartlett Street, Brooklyn, NY. 1. White Glove Professional Profile 2. Resume/Record of employment 3. Current New York State Registration (Original to be presented in person.) 4. Evidence of current malpractice insurance in the amount of $1/3 million. 5. Curent BCLS certification.) 6. Current clinical ANCC certifications (Home Health, Med Surg etc) 7. Documentation of annual attendance for mandatory education Fire Safety, Infection Control, HIV Confidentiality/HIPAA Compliance, Abuse, and Patient Safety Goals. 8. Annual Physician's statement of satisfactory health, including: drug screens, immunizations, Hepatitis B vaccine/waiver, neg PPD or chest x-ray. 9. Drivers license and evidence of auto insurance 10. W4 Form completed and signed. 11. I-9 Form Section 1 completed and signed. 12. Proof of eligibility to work in the U.S. or proof of citizenship Per I-9 Section 2. (Must be presented in person to authorized White Glove representative). 13. Two professional references from previous employers (forms enclosed if needed) 14. Skills Assessment (forms enclosed or may be completed online) 15. Completed and signed White Glove Orientation checklist. 16. Competency testing scheduled with recruiter. 17. Job description signed copy We greatly appreciate your taking the time to thoroughly complete the application requirements. Should you have any difficulty in sending us your documents, we will gladly provide assistance. We will make every effort provide for a rapid and uneventful employment process. Page 2 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE COMMUNITY CARE, INC. Community Care Professional Profile Kindly check one: RN LPN NP Therapist Other_____________ ___________________________________, _______________________________________ Last Name First Name Middle Name ______-_____-________ Social Security # _________________________________________________________ ____________________, _______ ___________ Home Address Apt. # City State Zip Code (_____)______-________(_____)______-______ _____−_____ (_____)______-_______ Home Phone # Work Phone # Shift on Duty (_______)________-___________ ____________________________ Other # E-Mail Address Beeper/Cell # ____/______/_____ Date of Birth In case of emergency notify: ___________________________________________________(______)_______-_________ Name, Relationship Address _____________ ______ _____/_____/_____ License # State Expiration Date Current NY Drivers License? Yes No Phone # ________________ Malpractice Co Auto Insurance? Yes _____________ _____/_____/_____ Policy # Expiration Date No Has your license or certification ever been investigated or suspended? Yes No Has any malpractice claim or suit ever been brought against you? Yes No Have you ever been convicted of a crime other than a minor traffic violation? Yes No If any of above is yes, please give explanation indicating dates, circumstances and final outcome: _________________________ ________________________________________________________________________________________________________ Specialty Experience Home Health yrs. CHHA LHCSA Private Duty Other Long Term Care yrs Adult Pediatric Rehab Center Other Med Surg Acute yrs Adult pediatric Sub acute Other The statements made in this application are true to the best of my knowledge. I understand that any falsification will be the basis for disqualification of employment or termination of services. I authorize White Glove Community Care, Inc. to verify the information I have provided and to contact past employers and references concerning my ability, character and employment record. I release all such persons from liability for furnishing said information. I authorize White Glove, as my employer, to release any medical and background information, which may be relevant to my assignment to its client facilities. By submitting this application to White Glove, I authorize release of this information to all other affiliates of the company and I acknowledge and agree that they may contact me using facsimile or any other means. Nothing contained in this employment application, or in the granting of an interview, is intended to create an employment contract between White Glove and the applicant for either employment or for providing of any benefit. All offers of employment are made conditional upon the applicant’s proving employment eligibility and identity in accordance with the Immigration Reform and Control Act of 1986. Signature__________________________________________________________ Date__/__/____ Page 3 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE COMMUNITY CARE, INC. Employee Confidentiality Statement – HIPAA As an employee of information at White Glove Community Care, Inc., assigned to a contracted facility/health care organization, you may develop, use, or maintain patient records (for health care, quality improvement, peer review, education, billing, reimbursement, administration, and research) or personnel records (for employment, payroll, or other business purposes). Patient and personnel information from any source and in any form, including paper record, oral communication, audio recording, and electronic display, is strictly confidential. Access to confidential patient and personnel information is permitted only on a need-to-know basis. It is the policy of White Glove Community Care, Inc. and their contracting hospitals and health care organizations that users (i.e., employees, medical staff, students, volunteers, and outside affiliates) shall respect and preserve the privacy of confidentiality of patient and personnel information. Violations of this policy include, but are not limited to: • • • • • • Accessing information that is not within the scope of your job; Misusing, disclosing without proper authorization, or altering patient or personnel information; Disclosing to another person your sign-on code and password for accessing electronic or computerized records; Using another person’s sign-on code and password for accessing electronic or computerized records; Leaving a secured application unattended while signed on; and Attempting to access a secured application without proper authorization. Violation of this policy by employees, staff, or volunteers may constitute grounds for corrective action up to and including termination of employment or loss of practice privileges in accordance with White Glove and the respective assigned contracting organization procedures and/or federal or state law. Violation of such policies may constitute grounds for corrective action in accordance with applicable policies and procedures of both White Glove Community Care, Inc., and the contracting organization. I have read and agree to comply with the terms of the above statement and will read and comply with the assigned hospital/health care organization’s policies and standards. I further certify that I have received training and instruction on the confidentiality provisions of the Medical Record Security and Privacy Regulations under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) or any other applicable patient confidentiality laws. Name: _________________________ (Please Print) SS#: _________________________ Signature: ______________________ Date___/___/____ Page 4 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE COMMUNITY CARE, INC. Record of Employment Name_____________________________________ Date _____/_____/_____ Give Present Employer First Facility Name________________________________________________ Employed From__________ to__________ Address____________________________________________________ City___________________ State________ Title_______ Clinical Area/Unit________________ Travel assignment? οYes οNo Average Patient Ratio________ Hours per Week_______ With which agency? _______________________ Supervisor_______________________________________ Phone # (_____)________-__________ Reason for Leaving___________________________________________________________________ Facility Name________________________________________________ Employed From__________ to__________ Address____________________________________________________ City___________________ State________ Title_______ Clinical Area/Unit________________ Travel assignment? οYes οNo Average Patient Ratio________ Hours per Week_______ With which agency? _______________________ Supervisor_______________________________________ Phone # (_____)________-__________ Reason for Leaving___________________________________________________________________ Facility Name________________________________________________ Employed From__________ to__________ Address____________________________________________________ City___________________ State________ Title_______ Clinical Area/Unit________________ Travel assignment? οYes οNo Average Patient Ratio________ Hours per Week_______ With which agency? _______________________ Supervisor_______________________________________ Phone # (_____)________-__________ Reason for Leaving___________________________________________________________________ Facility Name________________________________________________ Employed From__________ to__________ Address____________________________________________________ City___________________ State________ Title_______ Clinical Area/Unit________________ Travel assignment? οYes οNo Average Patient Ratio________ Hours per Week_______ With which agency? _______________________ Supervisor_______________________________________ Phone # (_____)________-__________ Reason for Leaving___________________________________________________________________ Education Name and Location of School High School __________________________________________________From ______-______ Degree______________ College __________________________________________________From ______-______ Degree______________ Graduate __________________________________________________From ______-______ Degree______________ School of Nursing__________________________________________________From ______-______ Degree______________ Page 5 9of 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com 21 WHITE GLOVE COMMUNITY CARE, INC. Physical Examination Report NAME____________________________________________DATE OF PHYSICAL_________________________ ADDRESS_________________________________________SOCIAL SECURITY #________________________ HEIGHT__________ WEIGHT__________ B/P__________ DATE OF BIRTH ___________ ________________________________________________________________________________________________ LABORATORY RESULTS Tuberculin Test-PPD nd 2 Step Date Administered___________ Read___________ Results_______________________ Date_______________________________ Results______________________________ Chest X-Ray (attache report) Date_______________________________ Results______________________________ Rubella Titer Rubeola Titer Mumps Titer Varicella Zoster Immunization date: ___________________ Immunization date: ___________________ Immunization date: ___________________ Immunization date: ___________________ Titer Results: _________________________ Titer Results: _________________________ Titer Results: _________________________ Titer Results: _________________________ Tetanus & Dipthertia Influenza Vaccine H1N1 Influenza Vaccine Date: ______________________________ Immunization Date: ______________________________ Immunization Date: ______________________________ If positive: Drug Screening (attach lab report) Date: ___________________ Results: _________________________ Hepatitis B Screening: Vaccine #1_________Vaccine #2_________Vaccine #3_________ Titer: _________ Complete CBC ____________________ Urinalysis___________________ VDRL _______________ Are there any factors affecting your health which would place patients, their families or fellow employees at risk or which would interfere with the performance of your job duties? These factors include, but are not limited to, habituation or active addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter your behavior. YES NO If yes, please describe. _____________________________________ ______________________________________ Do you take any prescription drugs or medications regularly? If yes, please describe usage, including dosage, frequency and purpose. _____________________________________________________________ ______________________________________________________________ Have you had any of the following: Yes No Yes No [ ] [ ] Chest pain [ ] [ ]Shortness of breath [ ] [ ] Dizziness [ ] [ ]Frequent headaches [ ] [ ]Ringing in your ears [ ] [ ]Double vision [ ] [ ]Change in your voice [ ] [ ]Chronic cough [ ] [ ]Sore that does not heal [ ] [ ]Drastic change in weight [ ] [ ]Loss/gain of 20lbs/more [ ] [ ]Recent change in your bowels [ ] [ ]Back pain [ ] [ ]Back injury-hospitalized [ ] [ ]Surgery in the past 5 years [ ] [ ]Hypertension [ ] [ ]abetes [ ] [ ]Allergies Yes [] [] [] [] [] [] [] [] [] No [ ]Ankle swelling [ ]Unexplained stomach pain [ ]Change in urination [ ]Night sweats [ ]GYN/GU problems [ ]Blood in stool [ ]Change in sleep patterns [ ]Unexplained fatigue [ ]Seizure condition RECOMMENDATION I CERTIFY THAT I HAVE EXAMINED THE ABOVE-NAMED INDIVIDUAL AND HAVE FOUND HIS/HER HEALTH TO BE SATISFACTORY TO WORK IN THE HEALTH CARE FIELD. PHYSICIAN’S SIGNATURE_______________________________________________ EXAM DATE____________________ PHYSICIAN’S NAME (Please print or stamp) ADDRESS _______________________________________________ LICENSE# _______________________________________________ TELEPHONE # _______________________________________________ ____________________ Page 6 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com TUBERCULOSIS SCREENING QUESTIONNAIRE ____________________________ Name ________________________ Date Positive TB skin test (PPD) Date: ___________________________________ Last Chest X-Ray Date:____________________________________________ Please indicate if you are having any of the following problems for three to four weeks or longer: 1. Chronic Cough (greater than 3 weeks) 2. Production of Sputum Yes______ Yes______ No_______ No_______ 3. Blood-Streaked Sputum Yes______ No_______ 4. Unexplained Weight Loss Yes______ No_______ 5. Fever Yes______ No_______ 6. Fatigue/Tiredness Yes______ No_______ 7. Night Sweats Yes______ No_______ 8. Shortness of Breath Yes______ No_______ NO EVIDENCE OF PULMONARY TUBERCULOSIS OR CONTAGIUM. _________________ Date _____________________________ Agency Employee Signature Page 7 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE COMMUNITY CARE, INC. Employee Hepatitis B Vaccine Waiver OSHA Guidelines Advocate that Health Care Workers to Take Hepatitis B Vaccination. This form is required only if you do not wish to obtain the vaccination series. I, ____________________________________(please print), have received information regarding the transmission of Hepatitis B and understand the occupational risks and OSHA guidelines as outlined. I do however, decline the Hepatitis B vaccination at this time for the following reasons: (PLEASE INDICATE BY PLACING A CHECKMARK BEFORE THE APPROPRIATE STATEMENT) I have completed the vaccination series (See Physical Exam) I have submitted titer reports, which document immunity (See Physical Exam). I have been advised by my physician not to receive vaccination for the following reason(s) (Please state) I have chosen to decline receiving the vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. Employee Signature ___________________________ Date _____/_____/_____ Page 8 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE COMMUNITY CARE, INC. Professional Employee Reference PLEASE PRINT NAME AND ADDRESS OF YOUR PREVIOUS EMPLOYER BELOW Facility: _________________________________________ Address: _________________________________________ City: __________________State: _______Zip: __________ To: _____________________________________________ Tel: ( ) -_________________________ Fax: ( ) -_________________________ Dear Employer: The following applicant has applied for employment with White Glove Community Care Home Health Program. Kindly provide the requested information to verify employment and prior experience to the best of your ability. The furnished information will be held in strict confidence and assist us in with the selection of qualified candidates. We do appreciate your time and thank you for your assistance. Print Name _____________________________________________________Social Security #: _______-_______-_________ Signature______________________________________________________ I Was Employed From _____/_____/_____To _____/_____/_____ Kindly Check One: RN PLEASE EVALUATE: LPN Experience Verified CNA Clinical Area_______________________________ NT Performance Met standards Other______________________ Performance Did not meet standards Performance not observed KNOWLEDGE OF Home Care Regulations KNOWLEDGE MED/SURG Nursing Practice Assessment Skills Care Planning Technical skills Communication skills ABILITY TO WORK INDEPENDENTLY ATTENDANCE & RELIABILITY ADDITIONAL COMMENTS:_(Overall Rating)___________________________________________________________________ REASON FOR LEAVING_(as applicable, if known)_____________________________________________________________________________ WOULD YOU CONSIDER APPLICANT FOR REHIRE? YES NO SIGNATURE_____________________________________________ DATE ______/______/______ Print Name and Title___________________________________________________Facility _________________ Page 9 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE COMMUNITY CARE, INC. Professional Employee Reference PLEASE PRINT NAME AND ADDRESS OF YOUR PREVIOUS EMPLOYER BELOW Facility: _________________________________________ Address: _________________________________________ City: __________________State: _______Zip: __________ To: _____________________________________________ Tel: ( ) -_________________________ Fax: ( ) -_________________________ Dear Employer: The following applicant has applied for employment with White Glove Community Care Home Health Program. Kindly provide the requested information to verify employment and prior experience to the best of your ability. The furnished information will be held in strict confidence and assist us in with the selection of qualified candidates. We do appreciate your time and thank you for your assistance. Print Name _____________________________________________________Social Security #: _______-_______-_________ Signature______________________________________________________ I Was Employed From _____/_____/_____To _____/_____/_____ Kindly Check One: RN PLEASE EVALUATE: LPN Experience Verified CNA Clinical Area_______________________________ NT Performance Met standards Other______________________ Performance Did not meet standards Performance not observed KNOWLEDGE OF Home Care Regulations KNOWLEDGE MED/SURG Nursing Practice Assessment Skills Care Planning Technical skills Communication skills ABILITY TO WORK INDEPENDENTLY ATTENDANCE & RELIABILITY ADDITIONAL COMMENTS:_(Overall Rating)___________________________________________________________________ REASON FOR LEAVING_(as applicable, if known)_____________________________________________________________________________ WOULD YOU CONSIDER APPLICANT FOR REHIRE? YES NO SIGNATURE_____________________________________________ DATE ______/______/______ Print Name and Title___________________________________________________Facility _________________ Page 10 of 21 White Glove Community Care, Inc 85 Bartlett St, Brooklyn, NY 11206 Page 11 of 21 WHITE GLOVE COMMUNITY CARE, INC. 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax:Page (718)12 782-1538 of 21 www.whiteglovecare.com Page 13 of 21 WHITE GLOVE FCOMMUNITY CARE, INC. Benefits & Policy White Glove offers exciting incentives to nurses, primarily having the money available in your account – no checks to cash. ♦ Direct Deposit – Money will be wired into any bank account you wish. Form enclosed. ♦ Access Advantage – You will receive an ATM card from White Glove’s bank (Bank of America). You can release your payroll in cash from any ATM machine across the country. Request an application from Mindy @ ext. #147. ♦ Annual Bonus/Vacation certificate – After working for one year, employees qualify to receive a cash bonus. At your first anniversary with us, please call Raizy @ ext. #183 to receive your bonus. ♦ Pretax Metro Cards – White Glove can purchase for you a Transit Check Metro Card at greater value from your pretax income. Request an application from Karen @ ext. #154. ♦ Dental Plan – The monthly premium for our Rayant Insurance Policy is as follows: *Single $48.67 *Employee and children $94.54 *Employee and Spouse $103.58 *Family $150.92 Request an application from Faigy @ ext. #135. ♦ Health Insurance – The monthly premium for our Health Net Insurance Policy is as follows: *Single $343.19 *Employee and children $634.93 *Employee and Spouse $764.31 *Family $1,021.63 Request an application from Faigy @ ext. #135. It is our mission here at White Glove to help every nurse receive the maximum in rates, benefits and employment opportunities. We will do everything in our ability to resolve any issue in a satisfactory manner. Good Luck, keep checking our new opportunities. Looking forward to a productive relationship! Payroll Policy: Hours Worked: Some clients allow nurses to work only 40 hours. Others have a provision for overtime. Hours worked over in excess of 40 hours, with prior approval from supervisor, will be paid at time and a half. Extra Hours at Shift: In order to get paid for extra time worked at shift, please indicate it when signing out. Payment for those hours will be subject to approval from a supervisor. Page 14 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com WHITE GLOVE FCOMMUNITY CARE, INC. Authorization Agreement For Automatic Deposits (ACH Credits) I (we) hereby authorize White Glove Community Care, Inc., hereinafter called COMPANY, to initiate credit Entries and to initiate, if necessary, debit Entries and adjustments for any credit entries in error to my (our) Checking Account Savings Account (select one) indicated below and the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account. DEPOSITORY NAME_________________________ BRANCH__________________________ CITY_________________________ STATE_____________ZIP____________ TRANSIT/ABA NO._____________ ACCOUNT NO.___________________ This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. NAME (S)_________________________________________ PLEASE PRINT) SOCIAL SECURITY #: __ __ __-__ __-__ __ __ __ DATE_______________ Kindly place copy of check below: SIGNED X____________________________ 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com Page 15 of 21 WHITE GLOVE FCOMMUNITY CARE, INC. • • • • • • Please fill-in the required information below. When completed mail this original form with proper employment ID to the Payroll Department. Your Access Advantage Account will be processed and your Fleet24 ATM card will be mailed to the designated address below. If alternate address is provided all correspondence regarding this account, as well as the Fleet24 ATM card, will be mailed to the alternate address. Your Access Advantage Account and ATM card will become active once you have received notification that your pay has already been deposited into your account. If you have any questions regarding this application, please feel free to contact our Payroll Department. YOUR NAME MOTHER’S MAIDEN NAME HOME ADDRESS (NO. AND STREET) APT. # CITY STATE ZIP ALTERNATE ADRESS (NO. & STREET) ONLY IF CARD IS TO BE MAILED TO DIFFERENT ADDRESS THAN LISTED ABOVE. CITY STATE SOCIAL SECURITY DATE OF BIRTH ZIP HOME PHONE BUSINESS PHONE EMPLOYER By signing below, I apply for a Fleet Access Advantage Account. I understand that I will receive a Fleet24 ATM card and have access to withdraw cash, make balance inquiries, and perform point of sale transactions via Fleet24, NYCE®, CIRRUS®, and Honor® ATMs (Customers who open their account in New Jersey can access the MAC® network). I have received a copy of the bank’s addendum and a copy for the fee information sheet. I agree to be bound by the terms of the sheet. Under penalties of perjury, I certify that: 1. 2. The Social Security Identification Number shown above is my correct taxpayer identification number (or I am writing for a number to be issued), and I am not subject to backup withholding because; (a) I am exempt from backup and withholding, (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. Check if subject to backup withholding Customer Signature______________________________________________ Date ______/_______/_______ BANK USE ONLY BANK # ____________________ COST CTR _____ ACCT # _____________________________________________ DATE OPENED ____/____/____ 85727D RM # _____________ 11/98 Non-Stock MC2 Fleet Access Advantage Account Addendum The rules and regulations of Fleet Personal Deposit Account Agreement except for the following will govern the Access Advantage Account: 1) The Access Advantage Account can only be accessed through an ATM (automatic teller machine) of POS (point of sale) terminal. No checks or other items can be drawn on the account. In an emergency, please contact your Fleet branch. 2) Non-Fleet ATM transactions and POS purchases are limited to a combination or four per statement cycle, otherwise, the following fees apply: Non-Fleet ATM withdrawal - $1.50 (Non-Fleet ATM transactions may be subject to other bank surcharge fees.) Non-Fleet ATM Balance Inquiry - $1.50 POS Purchase - $.25 3) Only funds electronically deposited by your employer will be accepted for deposit to the account. 4) Access Advantage accounts may not be opened as joint accounts. 5) If an Access Advantage Account remains inactive for 365 days with a zero balance, it will automatically close. 6) If at any time you would like to convert your Access Advantage Account to a traditional Fleet checking account, which would provide with additional features and services, please contact you local branch. Fee Schedule for Access Advantage Overdraft charge (per item) st Statement Copy (1 3 pages) Each additional page Duplicate statement Research (per hour) Legal Processing Abandoned Property Protest fee New fee amounts as of 7/1/99 CT $22 $5 $1 $6 $30 $50 N/A N/A MA $22 $5 $1 $6 $20 $50 N/A N/A Metro/LI $30 $5 $1 $6 $20 $100 $25 $20 Other NY $25 $5 $1 $5 $25 $100 $25 $15 NJ $30 $5 $1 $6 $25 $100 $25 N/A NH $25* $5 $1 $4 $20 $50 N/A N/A ME $22* $5 $1 $6 $20 $50 N/A N/A FL $30* $5 $1 $6 $30 $50 N/A N/A RI 22 $5 $1 $6 $15 $50 N/A N/A Page 16 of 21 PRINT CHARACTERS LIKE THIS ABCDE 98765 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com Consent to Request Consumer Report & Investigative Consumer Report Information Applicant's First Name or Initial Last Name I understand that White Glove Community Care (‘COMPANY’) will utilize the services of Sterling InfoSystems Inc., 249 West 17th Street, New York, NY 10011, (800) 899-2272 to obtain a consumer report and/or investigative consumer report as part of the procedure for processing my application for employment. I also understand that if my application for employment is granted, to the extent permitted by law, COMPANY may obtain further information through subsequent investigations by STERLING so as to update, renew or extend my employment. I understand Sterling InfoSystems Inc. (“STERLING”) investigation may include obtaining information regarding my credit background, bankruptcies, driving record, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support, accounts placed for collection, and criminal record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others whom I am acquainted or who may have knowledge concerning my character, general reputation, personal characteristics or standard of living. I understand that I have the right to receive notice about the nature and scope of any investigative consumer report requested within five days after the COMPANY receives my request or five days after the investigative consumer report was requested, whichever is later. By checking the box, I indicate that I wish to receive further disclosure about the nature and scope of any COMPANY request for an investigative consumer report. I acknowledge that I have received the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related state summary of rights. This consent will not affect my ability to question or dispute the accuracy of any information contained in my report. I understand if COMPANY makes a conditional decision to disqualify me based all or in part on my report, I will be provided with a copy of the report and another description in writing of my rights under the federal Fair Credit Reporting Act and, as required by law, any related state summary of rights, and if I disagree with the accuracy of the purported disqualifying information in the report, I must notify COMPANY within five business days of my receipt of the report that I am challenging the accuracy of such information with Sterling InfoSystems Inc. I hereby consent to this investigation and authorize COMPANY to procure a consumer report(s) and/or investigative consumer report on my background as stated above from a consumer reporting agency and/or investigative consumer reporting agency. In order to verify my identity for the purposes of background identification, I am voluntarily releasing my date of birth, social security number and the other information below for my own benefit and fully understand that all employment decisions are based on legitimate non-discriminatory reasons. Minnesota & Oklahoma Applicants Only: I have the right to request a copy of the consumer report obtained by COMPANY from STERLING by checking the box. STERLING will mail the consumer report directly to me. I wish to receive a copy of the consumer/investigative consumer report. (Check only if you wish to receive a copy.) Maine Applicants Only: By checking the box, I indicate that I wish to receive the name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries regarding the investigative consumer report. Washington State Applicants Only (AS APPLICABLE): I further understand that COMPANY will not obtain information about my “credit worthiness, credit standing, or credit capacity” unless the information is required by law, or is substantially job related, and the reasons for using the information are disclosed to me in writing. (If this option is checked, complete the question below.) Reasons why COMPANY considers information about “credit worthiness, credit standing, or credit capacity” as substantially job related: _______________________________________________________________________________________ NY Applicants Only: I also acknowledge that I have received the attached copy of Article 23A of New York’s Correction Law. I further understand that I may review and receive a copy of any investigative consumer report by contacting the consumer reporting agency. I further understand that I will be advised if any further checks are requested and provided the name and address of the consumer reporting agency. _________________________________________________________________________ ______________________ Signature Today’s Date Page 17 of 21 PRINT CHARACTERS LIKE THIS ABCDE 98765 N J H A W H I T E G L O V 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com E For Office Use Only – Group ID (optional) For Office Use Only – User ID (optional) For Office Use Only – Location / Store # (optional) First Name Middle Name or Initial Last Name Date of Birth (MMDDYYYY) Other Names Known By Social Security Number Male Primary Telephone Number (no dashes) Current Address City Female Apt # State Previous Address Zip Code Apt # City State Driver’s License Number (no dashes) License State #yrs at this address #yrs at this address Zip Code Email Address Signature Today’s Date (MMDDYYYY) Page 18 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com Para informacion en espanol, visite http://www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580. A Summary of Your Rights Under the Fair Credit Reporting Act The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to http://www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580. • You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information. • You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if: o a person has taken adverse action against you because of information in your credit report; o you are the victim of identify theft and place a fraud alert in your file; o your file contains inaccurate information as a result of fraud; o you are on public assistance; o you are unemployed but expect to apply for employment within 60 days. In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See http://www.ftc.gov/credit for additional information. • You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender. • You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See http://www.ftc.gov/credit for an explanation of dispute procedures. • Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate. • Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old. • Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access. • You must give your consent for reports to be provided to employers. A consumer-reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.ftc.gov/credit. Page 19 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688). • You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court. • Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit. States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are: FOR QUESTIONS OR CONCERNS REGARDING PLEASE CONTACT Consumer reporting agencies, creditors and others not listed below Federal Trade Commission Consumer Response Center- FCRA Washington, DC 20580 - 877-382-4357 National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name) Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 - 800-613-6743 Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks) Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 - 202-452-3693 Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name) Office of Thrift Supervision Consumer Programs Washington D.C. 20552 - 800- 842-6929 Federal credit unions (words "Federal Credit Union" appear in institution's name) National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 - 703-519-4600 State-chartered banks that are not members of the Federal Reserve System Federal Deposit Insurance Corporation Division of Compliance & Consumer Affairs Washington, DC 20429 - 877-275-3342 Air, surface, or rail common carriers regulated by Department of Transportation former Civil Aeronautics Board or Interstate Commerce Office of Financial Management Commission Washington, DC 20590 - 202-366-1306 Activities subject to the Packers and Stockyards Act, 1921 Department of Agriculture Office of Deputy Administrator-GIPSA Washington, DC 20250 - 202-720-7051 Page 20 of 21 New York Article 23-A Correction Law 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com § 750. Definitions. For the purposes of this article, the following terms shall have the following meanings: (1) “Public agency” means the state or any local subdivision thereof, or any state or local department, agency, board or commission. (2) “Private employer” means any person, company, corporation, labor organization or association which employs ten or more persons. (3) “Direct relationship” means that the nature of criminal conduct for which the person was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in question. (4) “License” means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that “license” shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) “Employment” means any occupation, vocation or employment, or any form of vocational or educational training. Provided, however, that “employment” shall not, for the purposes of this article, include membership in any law enforcement agency. § 751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for employment made by a prospective employee or previously made by a current employee. § 752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely by reason of the individual’s having been previously convicted of one or more criminal offenses, or by reason of a finding of lack of “good moral character” when such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses, unless: (1) there is a direct relationship between one or more of the previous criminal offenses and the specific license or employment sought or held by the individual; or (2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk to property or to the safety or welfare of specific individuals or the general public. § 753. Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein. § 754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a written statement setting forth the reasons for such denial. § 755. Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to article seventy-eight of the civil practice law and rules. 2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city commission on human rights. Page 2 of 21 85 Bartlett Street, Brooklyn, NY 11206 Phone: (718) 387-8181, (866) 387-8100 Fax: (718) 782-1538 www.whiteglovecare.com VOLUNTARY SELF-IDENTIFICATION FOR EMPLOYMENT APPLICANT We have received and appreciate your expression of interest in employment with White Glove. White Glove is committed to a policy of equal opportunity in accordance with all Equal Opportunity/Affirmative Action laws and regulations. For federal record keeping purposes, White Glove is required to gather and maintain certain information on individuals who apply for employment with us. The information you provide below will not be used to make any employment-related decisions. The information you provide below is voluntary, and refusal to provide this information will not result in any adverse treatment. Regardless of whether you provide the gender and race/ethnic group information, please enter your name in the space provided below, enter the position for which you applied and the date you applied for that position. Please check the categories which apply to you: GENDER INFORMATION: Male Female ETHNIC GROUP/RACE INFORMATION: Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.) Yes No If you answer “No”, please check all that apply to you: White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa. Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. Native Hawaiian or Other Pacific Island (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. American Indian or Alaskan Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North or South America (including Central America), and who maintain tribal affiliation or community attachment. ********************************************************************************************* I do not wish to Self-Identify Name: _________________________________________ Date: _____________________________________ Position Applied For: __________________________________________
© Copyright 2024