Vacancies For Job Seekers - K&A Healthcare Services

Applicant Name:*
Address:*
City, State and Zip Code:*
Telephone Number*
Email Address*
Date of Application*
MM slash DD slash YYYY
Employment Position

Position(s) applying for:
How did you hear about this position?
What days are you available for work?*
What hours or shift are you available for work?*
If needed, are you available to work overtime?*
On what date can you start working if you are hired?*
Do you have reliable transportation to and from work?*
Salary desired:*
Personal Information
Have you ever applied to or worked for K & A Nursing Staffing Agency before?*
- Yes
- No
If yes, when?*
Do you have any friends, relatives, or acquaintances working for K & A Nursing Staffing Agency:*
- Yes
- No
If yes, state name & relationship:*
Are you 18 years of age or older?*
- Yes
- No
Are you a U.S. citizen or approved to work in the United States?*
- Yes
- No
What document can you provide as proof of citizenship or legal status?*
Will you consent to a mandatory controlled substance test?*
- Yes
- No
Do you have any condition which would require job accommodations?*
- Yes
- No
If yes, please describe accommodations required below.*
Have you ever been convicted of a criminal offense (felony or misdemeanor)?*
- Yes
- No
If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:*

Job Skills/Qualifications
Please list below the skills and qualifications you possess for the position for which you are applying:*
(Note: K & A Nursing Staffing Agency complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional. )
Education and Training

High School
Name of High School*
Location of High School (City, State)*
Year Graduated From High School*
Degree Earned at High School*
College/University
Name of College/University*
Location of College/University (City, State)*
Year Graduated From College/University*
Degree Earned at College/University*
Vocational School/Specialized Training
Name of Vocational School/Specialized Training*
Location of Vocational School/Specialized Training (City, State)*
Year Graduated From Vocational School/Specialized Training*
Degree Earned at Vocational School/Specialized Training*
Military
Are you a member of the Armed Services?*
What branch of the military did you enlist?*
What was your military rank when discharged?*
How many years did you serve in the military?*
What military skills do you possess that would be an asset for this position?*

Previous Employment
Employer Name*
Job Title:*
Supervisor Name:*
Employer Address:*
City, State and Zip Code:*
Employer Telephone:*
Dates Employed:*
Reason for leaving:*
Employer Name:*
Job Title:*
Supervisor Name:*
Employer Address:*
City, State and Zip Code:*
Employer Telephone:*
Dates Employed:*
Reason for leaving:*
Employer Name:*
Job Title:*
Supervisor Name:*
Employer Address:*
City, State and Zip Code:*
Employer Telephone:*
Dates Employed:*
Reason for leaving:*

References
Please provide 3 personal and professional reference(s) below:
Reference 1*
Reference 1 Contact Information*
Reference 2*
Reference 2 Contact Information*
Reference 3*
Reference 3 Contact Information*

Additional Information
What makes you a proficient nurse?*
AT-WILL EMPLOYMENT
The relationship between you and the K & A Nursing Staffing Agency is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the K & A Nursing Staffing Agency. No representative of K & A Nursing Staffing Agency has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.
Applicant Signature:*
Dated:*
MM slash DD slash YYYY

CONFIDENTIALITY AND NON-COMPETITION AGREEMENT
The Agency requires that the Employee avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition.

The Employee agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding employees, clients and the Agency business.

The Employee will have access to information not generally made available to the public, such as identity of clients, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purposes other than for the Agency’s own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to Agency administration and/or projects, or outside investigations of the Agency. The employee is prohibited from disclosing any defaming information regarding Agency personnel and/or personnel incidents related to any violations of the personnel policies.

During the course of employment and for a twelve month period thereafter the Employee is prohibited from engaging in any of the following: induce any employee of the Agency to resign, encourage any client or entity to discontinue any relationship with the Agency, solicit any client of the Agency (current and within the past twelve month period), enter into competitive employment or seek to provide competitive services while employed within the twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source.

Upon termination of employment or at the request of the Agency, the Employee is required to return all of the Agency’s property including keys, client records, forms, manual, beeper, etc. to the Agency and will not retain copies. Failure to return a key will result in a $25.00 charge and failure to return a beeper will result in a $50.00 charge deducted from the paycheck.

Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, cost of replacing and training employees improperly solicited for competitive employment, etc. suffered by the Agency. Employee will be required to reimburse the Agency for all legal fees, costs and other expenses.

This agreement is in effect during the Employee's employment and for twelve months thereafter. It does not modify the right of the Employee to resign at any time or of the Agency to terminate employment without prior cause, notice or liability and does not modify any other Agency policy.
Employee Signature*
Date*
MM slash DD slash YYYY

LAST NAME*
FIRST NAME*
MIDDLE NAME*
MAIDEN NAME (OR OTHER NAME(S) BY WHICH YOU HAVE BEEN KNOWN)*
DATE OF BIRTH*
MM slash DD slash YYYY
PLACE OF BIRTH*
SEX:*
HEIGHT: (FT.)*
HEIGHT: (IN.)*
EYE COLOR:*
RACE:*
DRIVER'S LICENSE/ID # & STATE OF ISSUE*
SOCIAL SECURITY NUMBER*
FATHER'S LAST NAME:*
FATHER'S FIRST NAME*
MOTHER'S LAST NAME*
MOTHER'S FIRST NAME*
MOTHER'S MAIDEN NAME:*
CURRENT ADDRESS:*
STREET NAME & NUMBER CITY/TOWN STATE ZIP
FORMER ADDRESS*
STREET NAME & NUMBER CITY/TOWN STATE ZIP
THE ABOVE INFORMATION WAS VERIFIED BY REVIEWING THE FOLLOWING FORM(S) OF GOVERNMENT ISSUED IDENTIFICATION:*
VERIFIED BY:
NAME OF VERIFYING EMPLOYEE*
SIGNATURE OF VERIFYING EMPLOYEE*

Employee's Withholding Certificate
► Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
► Give Form W-4 to your employer.
► Your withholding is subject to review by the IRS.
Form W-4
Department of the Treasury
Internal Revenue Service
OMB No. 1546-0074
2020
Step 1: Enter Personal Information*
(a) First name and middle initial Last name
(b) Social Security*
Address*
Address City or town State ZIP code
(c)*
- Single or Married filing separately
- Married filing jointly (or Qualifying widow(er))
- Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.
Step 2: Multiple Jobs or Spouse Works Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4); or
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay: otherwise, more tax than necessary may be withheld
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.
Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying jobs.)
Step 3: Claim Dependents If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000*
Multiply the number of other dependents by $500*
Add the amounts above and enter the total here*
3
Step 4 (optional): Other Adjustments
(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income*
4(a)
(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here*
4(b)
(c) Extra withholding. Enter any additional tax you want withheld each pay period*
4(c)
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Employee's Signature*
(This form is not valid unless you sign it.)
Date*
MM slash DD slash YYYY
Employers Only
Employer’s name and address
Employer’s name*
Address*
First date of employment*
MM slash DD slash YYYY
Employer identification number (EIN)*

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
FORM I-9
OMB No. 1615-0047
►START HERE. Read Instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of FORM I-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)*
First Name (Given Name)*
Middle Initial*
Other Names Used (if any)*
Address*
Address (Street Number and Name) Apt. Number City or Town State Zip Code
Date of Birth (mm/dd/yyyy)*
MM slash DD slash YYYY
Social Security*
E-mail Address*
Telephone Number*
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
A citizen of the United States*
- A citizen of the United States
A noncitizen national of the United States (See instructions)*
- A noncitizen national of the United States (See instructions)
A lawful permanent resident (Alien Registration Number/USCIS Number):*
- A lawful permanent resident (Alien Registration Number/USCIS Number):
Alien Registration Number/USCIS Number*
An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):*
- An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Expiration Date*

Some aliens may write "N/A" in this field. (See instructions)
For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number:
1. Alien Registration Number/USCIS Number:*

OR
2. Form I-94 Admission Number:*
If you obtained your admission number from CBP in connection with your arrival in the United States, include the following:
Foreign Passport Number:*
Country of Issuance:*
Some aliens may write “N/A” on Foreign Passport Number and Country of Issuance fields. (See instructions)
Signature of Employee:*
Date (mm/dd/yyyy):*
MM slash DD slash YYYY
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.)
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator:*
Date (mm/dd/yyyy):*
MM slash DD slash YYYY
Last Name (Family Name)*
First Name (Given Name)*
Address*
Address (Street Number and Name) City or Town State Zip Code

Employee Direct Deposit Authorization Agreement

Instruction: Please fill in your name, check off appropriate box(s), complete all 5 five lines of bank information, sign, date, and print employer name. Also include a copy of a voided check or savings deposit form that corresponds to this account. Eagle Payroll Service will not accept this direct deposit from if it is incomplete. Please fill out a separate form for each bank account you wish to have direct deposit activated. This request will be submitted to your bank upon your employers' next live payroll.
Due to mandatory bank pre-nothing(testing), Direct Deposit Service will go into effect approx. 10 business days from the date of your employers' next payroll processing!
Employer (Company) Name*
Employee Name I (we) hereby authorize Eagle Payroll Service , Inc. ("EPSI") to deposit funds by electronically initiating credit entries to my account(s) at the financial institution(s) (the "BANK") indicated below. I further authorize this BANK to accept and credits entries initiated by EPSI to my checking and/or savings account(s). I acknowledge any deposit is an advance of funds by Eagle on behalf of my employer, and is subject to the successful collection of funds for this transaction, and/or an erroneous deposit was made to my account, I hereby authorize and give permission to EPSI to EPSI to debit my account to recover said funds. I agree to hold EPSI harmless from loss and indemnify it, limited to the amount of deposit.
*
- New Request
- Change Request
- Stop Existing Request
- In addition to Existing Requests
1. Name of Bank, savings & loan or credit union*
2. Bank Routing/transit number*
3. Employee account number*
4. Type of account (please check one)*
- Checking
- Savings
5. Deposit fixed dollar amount? $ or Deposit Percent of Net pay amount?%
PLEASE ATTACH A COPY OF A VOIDED CHECK (FOR CHECKING ACCOUNT) AND/OR A COPY OF A DEPOSIT SLIP (SAVINGS ACCOUNT)*
Max. file size: 100 MB.
Eagle a payroll service cannot accept direct deposit requests without the above necessary information!
This agreement (authority) is to remain in full force and effect until above employee is either terminated from employment or terminate the agreement by written notification to employer. In turn, the employer will notify EPSI, and give sufficient and reasonable time for EPSI to act upon the termination request.
Employee Signature*
Date*
MM slash DD slash YYYY

EMPLOYEE EMERGENCY CONTACT FORM

Employee Information
Name:*
Address*
Street Address City: Zip Code:
Home Phone:*
Cell Phone:*
Email:*
Allergies:*
PRIMARY EMERGENCY CONTACT
Name:*
Home Phone:*
Cell Phone:*
Relationship:*
SECONDARY EMERGENCY CONTACT
Name:*
Home Phone:*
Cell Phone:*
Relationship:*
Name*
First Last
Driver license*
Max. file size: 100 MB.
Certification*
Max. file size: 100 MB.
Green card*
Max. file size: 100 MB.
Social security card*
Max. file size: 100 MB.
Physical*
Max. file size: 100 MB.
TB*
Max. file size: 100 MB.
CPR*
Max. file size: 100 MB.
Resume*
Max. file size: 100 MB.
Email
This field is for validation purposes and should be left unchanged.

Careers

Employee Forms

Applicant Information:

Step 1 of 12

Employment Position

Personal Information

Job Skills/Qualifications

Education and Training

High School

College/University

Vocational School/Specialized Training

Military

Previous Employment

References

Additional Information

AT-WILL EMPLOYMENT

CONFIDENTIALITY AND NON-COMPETITION AGREEMENT

Tuberculosis Questionaire

Tuberculosis Questionaire

TB History

Employee's Withholding Certificate

Employment Eligibility Verification

Employee Direct Deposit Authorization Agreement

EMPLOYEE EMERGENCY CONTACT FORM

Employee Information

PRIMARY EMERGENCY CONTACT

SECONDARY EMERGENCY CONTACT

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