Preferred Home Care, Inc

EXPERT IN HOME HEALTH MANAGEMENT PAYROLL/NEW HIRE/CHANGE OF STATUS

LAST NAME: ______FIRST NAME______MIDDLE INITIAL______SOC SEC NUMBER: _____ -_____ -______DR.LICENSE # ______ADDRESS: ______PHONE: (_____)______CITY ______STATE:______ZIP:______EMERGENCY CONTACT: ______PHONE: ______RELATIONSHIP: ______(THE FOLLOWING INFO IS USED FOR BACKGROUND CHECKS ONLY)

D.O.B. _____/_____/______PLACE 0F BIRTH (STATE)______(COUNTRY)______HEIGHT______WEIGHT______HAIR COLOR______EYE COLOR______RACE ______MALE______FEMALE______PROF. LICENSE #______

(OFFICE USE ONLY BELOW THIS BOX)

DEPT/STATUS:  OFFICE  FULL TIME  RN  OT  FULL TIME  PART TIME  LPN  OTA  PART TIME  TEMPORARY  PT  ST  PRN  PTA  CHHA

 NEW HIRE DATE_____/____/_____  RE HIRE DATE_____/______/_____  PROMOTION DATE_____/____/_____  TERMINATION DATE_____/______/______ CHANGE OF ADDRESS  CHANGE W4 WITHHOLDING  CHANGE OF PHONE#  STATUS CHANGE  CHANGE PAY RATE  OTHER______

JOB TITLE: ______

CHANGE EFFECTIVE DATE: ______/______/______

PAY RATE:  HOURLY ______ BI-WEEKLY ______ FEE FOR SERVICE:______NOTES:______

ATTACHMENTS:  FEDERAL W4  STATE W4  I-9  MEMO OTHER ______

NEW HIRE REPORT SUBMITTED:  YES  NO DATE: ______

HUMAN RESOURCES: ______DATE: ______

ADMINISTRATION: ______DATE: ______