YOUR QUALIFICATIONS

Our Requirements

We seek professionals driven to provide quality home health care synonymous with the Unicare name.

Professional
Certification

You are professionally certified and trained as a home health aide.

Responsible
& Caring

You are kind, warm and caring and duty-bound to an assigned job.

Flexible
Schedule

Candidates willing to take on flexible and overnight cases are preferred.

Bilingual
Capability

Bilingual proficiency is a plus in working with our broad range of clients.

Personal Info,
Qualifications and References

Please provide all the requested information in the form below and we will get back to you shortly.
English Spanish

    First Name*

    Last Name*

    Birthdate

    Social Security number

    Address

    City

    State

    Postal Code

    House number

    Cell phone number

    Email

    Applied Position

    Emergency Contact Information

    Emergency contact

    Emergency relationship

    contact #

    Employment History


    Name of the company

    Phone number

    Address

    Job title

    Supervisor Name

    Name of the company

    Phone number

    Address

    Job title

    Supervisor Name

    Personal References/Referencias Personales

    Reference Name

    Relationship

    time to meet

    Email

    Phone number

    Reference Name

    Relationship

    time to meet

    Email

    Phone number

    (Date)

    Reference Request

    I have applied for a position at Unicare. I authorize the above-named individual / company to provide requested reference information.

    I hereby release from all liability the company, institution or individual releasing such information.

    Referee Information

    For Internal Use Only. Please refrain from filling out the rest of this form.

    Satisfactory

    Unsatisfactory

    Unable to Evaluate

    Comments

    Personal Qualities

    Productivity

    Attendance

    Punctuality

    Initiative

    Dependability

    Appearance

    Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law for Home Care Aides Wage Parity and Other Jobs

    NYC LS62

    1. Employer Information

    Efficient Health Careers, Inc

    Unicare Home Care

    132 32nd Street, suite 405 Brooklyn, NY, 11232

    same as above

    718-322-3555

    2. Notice given:

    Note: Live-in employees must be paid at least 13 hours for each 24 hour period, provided they receive 8 hours of sleep, with five hours of uninterrupted sleep and 3 hours off for meals. If an employee does not receive 5 hours of uninterrupted sleep, the employee must be paid for all 8 hours. If the employee does not receive meal periods free from duty, the employee must be paid for all 3 hours designated for meals.

    $ per hour for

    $ per hour for

    $ per hour for

    $ per hour for regular wage

    $ per hour for additional wage

    $ per hour for supplemental wages*

    6. Pay is:

    Single Pay Rate: $ per hour

    This must be at least 1½ times the worker’s regular rate with few exceptions.

    Wage Parity Pay Rate: $ per hour

    This must be at least 1½ times the worker’s regular rate with few exceptions.

    Multiple Pay Rates: $ per hour

    This must be at least 1½ times the worker’s Weighted average of the multiple rates of pay for the week, with few exceptions.

    8. Employee Acknowledgement:

    On this date, I have been notified of my pay rate, overtime rate (if eligible), allowances, supplements and designated payday. I told my employer what my primary language is.


    .

    I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary language.

    The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

    Please note: It is unlawful for an employee with protected class status to be paid less than an employee without protected class status, if they are performing substantially equal work. Employers also may not prohibit employees from discussing wages with their co-workers.

    LS 62 Notice to Wage Parity Home Care Aides - (cont’d) Benefit Portion of Minimum Rate of Home Care Aide Total Compensation

    Hourly Rate

    Type of Supplement

    Name & Address of Provider

    Agreement/ Plan Information

    Supplement Number

    $ XXX

    (Pension, Welfare, or Other)

    Insert Name and Address of Company or Organization Providing Benefit

    Identify plan or agreement that creates the benefit, e.g., Union Local No. 1 Collective Bargaining Agreement or Insurance Company X Benefit Plan

    Supplement Number 1

    1.00

    Additional Wages

    Efficient Health Careers

    Supplement Number 2

    2.29

    Mec

    Supplement Number 3

    .80

    PTO

    *If wage supplements are paid as a single payment owed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

    List any additional benefits and attach listing to this document.

    Employee Acknowledgement:

    On this day I have been notified of my pay rate, overtime rate, allowances, supplements/benefits, and designated payday provided on this form (LS 62) attached and this addendum on the date given below.

    .

    HOME HEALTH AIDE/PERSONAL CARE AIDE AFFIDAVIT

    I have applied for a position as HOME HEALTH AIDE (HHA)/PERSONAL CARE AIDE (PCA) with Unicare Home Care. All of the information I have submitted is true to the best of my knowledge. All certificates are valid (or copies of originals) and all background information is correct. I authorize Unicare Home Care to obtain any information regarding and pertaining to my employment and health status. I understand that this may include contacting the following to obtain information to verify signatures, dates, forms and data: Medical Providers (M.D. Lab Reports, etc. ), Previous Employer, Schools and Training Programs, Personal and Professional References.

    I further release Unicare Home Care of any liability that may occur as a result of my personal negligence or as a result of any information that I wrongfully or fraudulently submitted, which will result in my immediate termination. As a job applicant/employee of Unicare Home Care, I hereby attest to the fact that I have received no special inducements, remuneration or promises thereof to work for this agency. I understand that I will receive a salary commensurate and also in line with what other employees of this agency are receiving for similar work and experience. Hiring of personnel, salaries, and benefits are awarded without regard to race, religion, disability, marital status or sexual orientation. Unicare Home Care is an equal opportunity employer. All other benefits that I may be eligible for will be in accordance with policies established by Unicare Home Care.

    I have applied for a position as a HOME HEALTH AIDE with Unicare Home Care. All the information I have submitted is true to the best of my knowledge. All certificates are valid (or copies of originals) and all background information is correct. I authorize Unicare Home Care to get information about my employment and health status. I understand that this may include contacting the following to obtain information for verify signatures, dates, forms and data: Medical providers (M.D. Lab reports, etc.), Previous employers, Schools and programs training, Personal and Professional References.Furthermore, I release Unicare Home Care from any liability that may occur as a result of my personal negligence or as a result of any information I have misrepresented or fraudulently will result in my immediate termination As a job applicant/employee of Unicare Home Care, I attest that I have received no special incentives, compensation or promises to work for this agency. I understand that I will receive a salary commensurate and also in line with what other employees of this agency are receiving for similar work and experience. All other benefits for which you may be eligible will be in accordance with the policies established by Unicare Home Care. Hiring of personnel, salaries and benefits are granted without regard to race, religion, disability, marital status or sexual orientation. Unicare Home Care is an equal opportunity employer. I have read the above statement and understand and agree according to its content.

    All Unicare Home Care personnel are required to follow the Rules of Conduct and avoid actions that result in conflict of interest.All Unicare Home Care personnel must follow the Rules of Conduct and avoid actions that create conflicts of interest.

    I am aware that I cannot and will not work for other licensed or certified home care agency or any other organization during my scheduled time for which I am providing aide services to a patient of Unicare Home Care. Misrepresentation or falsification of any information may result in disciplinary action or termination. I hereby certify that I have read the above statements and that the information provided in this Acknowledgement Form is true and correct to the best of my knowledge. I have read the preceding statement and I understand and agree with its contents.

    I am aware that I cannot and will not work for another licensed or certified home care agency or any other organization during my scheduled time that I am providing home health aide services to a Unicare patient homecare. Misrepresentation or falsification of any information may result in disciplinary action or termination. Hereby I certify that I have read the above statements and that the information provided in this Acknowledgment Form is true and correct to my best knowledge and belief.

    Print Name

    Date

    Applicant’s Signature *

    Form W-4

    Department of the Treasury Internal Revenue Service

    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.

    OMB No. 1545-0074

    2023

    Step 1: Enter Personal Information

    Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

    (c)Single or Married filing separatelyMarried filing jointly or Qualifying surviving spouseHead 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, other details, 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.


    (a)
    (b)
    (c)

    TIP: If you have self-employment income, see page 2.

    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 job.)

    Step 3: Claim Dependent and Other Credits

    If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

    $

    $

    $

    Step 4 (optional): Other Adjustments

    $

    $

    $

    Step 5: Sign Here

    Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

    Employers Only

    For Privacy Act and Paperwork Reduction Act Notice, see page 3.

    Cat. No. 10220Q

    Form W-4 (2023)

    Department of Taxation and Finance

    Employee’s Withholding Allowance Certificate

    New York State • New York City • Yonkers

    IT-2104


    Note: If married but legally separated, mark an X in the Single or Head of household box.

    Before making any entries, see the Note below, and if applicable, complete the worksheet in the instructions.

    1. Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 19, if using worksheet)

    2. Total number of allowances for New York City (from line 31, if using worksheet)

    3. Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

    4. New York State amount

    5. New York City amount

    6. Yonkers amount

    I certify that I am entitled to the number of withholding allowances claimed on this certificate.
    Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

    Employee: Give this form to your employer and keep a copy for your records. Remember to review this form once a year and update it if needed.
    Note: Single taxpayers with one job and zero dependents, enter 1 on lines 1 and 2 (if applicable). Married taxpayers with or without dependents, heads of household or taxpayers that expect to itemize deductions or claim tax credits, or both, complete the worksheet in the instructions. Visit www.tax.ny.gov (search: IT-2104-I) or scan the QR code below.
    Employer: Keep this certificate with your records.
    If any of the following apply, mark an X in each corresponding box, complete the additional information requested, and send an additional copy of this form to New York State. See Employer in the instructions. Visit www.tax.nys.gov (search: IT-2104-I) or scan the QR code below.

    You may report new hire information online instead of mailing the form to New York State. Visit www.nynewhire.com.
    Note: Employers must report individuals under an independent contractor arrangement with contracts in excess of $2,500 using the online reporting website above, not Form IT-2104.

    Form 8850

    (Rev. March 2016)

    Department of the Treasury Internal Revenue Service

    Pre-Screening Notice and Certification Request for the Work Opportunity Credit

    a Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.

    OMB No. 1545-1500

    Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

      • 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:

        1. Received SNAP benefits (food stamps) for the past 6 months; or

        2. 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 SNAP benefits (food stamps) for the past 6 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.

    Signature—All Applicants Must Sign

    Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.

    For Privacy Act and Paperwork Reduction Act Notice, see page 2.

    Cat. No. 22851L

    Form 8850 (Rev. 3-2016)


    Please fill in these forms and legibly.(NO script)

    (Enter state where UI compensation was received)

    This company participates in various federal and state tax credit programs. This information in no way will negatively impact any hiring, retention decision. Your responses to the questions will only be shared with your employer’s management and federal, state, or local govern mental agencies as needed in administration of these 5 programs. By completing this form, you knowingly and voluntarily waive any objection to providing your social security number. Any information provided will be used in a manner consistent with the American Disability Act. Under penalty of perjury, I certify that this information is true and correct to the best of my knowledge. I hereby authorize this company’s management, and federal, state, and local government agencies to provide information I to Tax Opportunities America and/or SWA, to determine eligibility. I understand that the information above may be subject to verification.

    For any questions, email info@taxoa.com, or call 718.705.9003

    U.S. Department Labor Employment and Training Administration

    OMB Control No. 1205-0371

    Expiration Date: January 31, 2020

    LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM Work Opportunity Tax Credit (WOTC) Program

    Instructions: This Self-Attestation Form (SAF) is to be completed, signed, and dated by the new hire only. Employers or consultants submit this SAF to the State Workforce Agency with IRS Form 8850 or if filed separately, with ETA Form 9061 (or ETA Form 9062) for each certification request filed for the new target group.

    Under penalties of perjury, I declare that this information is true and correct to the best of my knowledge.

    (Enter last four digits)


    Privacy Act Notice:

    The Internal Revenue Code of 1986, Section 51, as amended and its enacting legislation, P.L. 104-188, specify that the State Workforce Agencies are the "designated" agencies responsible for administering the WOTC certification procedures of this program. The information you have provided completing this form will be disclosed by your employer to the State Workforce Agency. Provision of this information is voluntary; however the information is required to determine your employer's eligibility for the federal tax credit.

    Public Burden Statement:

    Persons are not required to respond to this collection of information unless it displays a currently valid OM B control number. Respondents' obligation to complete this form is required to obtain or retain benefits (P.L. 111-5). Public reporting burden is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding this burden estimate to the U.S. Department of Labor, Division of National Programs Tools Technical Assistance, Room C-4510, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371). Please do not submit completed forms to this address.

    ETA Form 9175 (Rev. November 2016)

    ONLY FILL OUT IF YOU ARE 16-24 YEARS OLD

    New York Urban Youth Jobs Program

    I am currently unemployed, I was unemployed prior to completing this application or I do not have enough paid work or work that is adequate with respect to my skills and training. *

    I am 16 or 17 years old and have the permission of my parent of guardian to submit this application: *


    I am 18 to 24 years old:

    Categories

    • 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 am homeless.

    • I consider myself to have a different risk factor not identified in the above list.

    Agreement

    I swear that I currently meet the qualifications listed above in the New York Youth Jobs Program: Youth Certification Qualifications section.
    I understand that I must provide private, personal information on this application to qualify for the program. I understand that I do not need to explain why I qualify to anyone I ask for a job, or who gives me a job, or anyone who I work with. I agree to allow the New York State Department of Taxation and Finance to share my wage record with the New York State Department of Labor. I believe the information submitted in this application is true, correct and complete. I understand that the New York State Department of Labor will make sure the information submitted in this application is true and may ask me for more information or details. I am aware that there are consequences for filing false documents or other information with the government.
    I agree to the statements above.

    DIRECT DEPOSIT AUTHORIZATION FORM

    Please print and complete ALL the information below

    (Full name)

    (Street, Address)

    City

    State

    Postal Code

    (Name of the bank)

    (Account number)

    (Route number)

    (Amount)

       

     


    I hereby authorize Unicare Home Care to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account indicated above and authorize to directly deposit my pay to the account as listed above. This authorization will remain in effect until I modify or cancel it in writing.

    (Full name)

    (Date)

    CHRC SUBMISSION FORM

    The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

    First name

    middle initial

    Surnames

    Last 4 Digits of Social Security Number

    Single name

    If any

    Type of address

    Street #

    Name of the street

    Department #

    Gender

    Race

    Height

    Weight

    Eye color

    hair color

    Country/Place of birth

    City

    State

    Postal Code

    Home phone

    Cell phone

    Unicare Home Care does not discriminate because of sex, age, physical handicap, race, creed or national origin. The Agency is an equal opportunity employer.

    Unicare Home Care does not discriminate on the basis of sex, age, physical disability, race, creed, or national origin. The agency is an equal opportunity employer.

    The information listed in my application is complete and true. I understand that if employed, false statements on this application are cause for dismissal. I will comply with all of the agency's rules and regulations regarding my employment. Unicare Home Care may request information regarding my background, which will include work and personal references.

    The information on my application is complete and true. I understand that if used, false statements on this application are grounds dismissal. I will comply with all agency rules and regulations regarding my employment. Unicare Home Care may request information regarding my background, which will include work and personal references.

    (Date)

    NEW YORK STATE DEPARTMENT OF HEALTH

    Criminal History Record Check

    Department of Health

    DOH CHRC form 102: Acknowledgement and Consent for Fingerprinting and Disclosure of Criminal History Record Information
    The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

    SECTION 1 – SUBJECT INDIVIDUAL INFORMATION

    SECTION 2 – ATTESTATION

    1.

    I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI).

    2.

    I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI.

    3.

    I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary. In accordance with applicable laws, DOH will furnish appropriate summary information to the agency to which I applied for a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I have a criminal history, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be disclosed to persons authorized by law. I have been informed that upon receiving notification from DCJS that there is a subsequent pending criminal action or proceeding or conviction, the DOH shall promptly notify an authorized person(s) of a provider of the additional allegation or new conviction.

    4.

    I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place.

    5.

    I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI. If I believe an error has been made by DCJS for any New York State conviction/charge or the FBI for a non-New York State conviction/charge, I understand that I should notify DCJS and/or the FBI to report and request correction of this error to the addresses below.

    NYS Division of Criminal Justice Services Criminal History Bureau
    Record Review Unit-5th Floor
    4 Tower Place, Albany, NY 12203
    (518) 485-7675

    Federal Bureau of Investigation
    Criminal Justice Information Services (CJIS) Division
    1000 Custer Hollow Road, Clarksburg, WV 26306
    (304) 625-5590

    6.

    I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information.

    7.

    I certify to the best of my knowledge and belief that I (check as appropriate): *

    8.

    My current mailing or home address is indicated in Section 1 of this form.

    9.

    I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the re-disclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency in accordance with applicable laws. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own.

    (if subject individual is under 18 years of age)

    SECTION 3 – AGENCY AUTHORIZED PERSON INFORMATION

    This form is to be retained by the agency. Do not forward to the DOH CHRC

    Employment Eligibility Verification Department of Homeland Security

    U.S. Citizenship and Immigration Services
    USCIS Form I-9

    OMB No. 1615-0047

    Expires 10/31/2022

    START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

    ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ 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.)

    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.

    1.

    2.

    3. (Alien Registration Number/USCIS Number):

    4. (expiration date, if applicable, mm/dd/yyyy):

    Some aliens may write "N/A" in the expiration date field. (See instructions)
    Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

    OR

    OR

    Preparer and/or Translator Certification (check one):


    (Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

    I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

    Employment Eligibility Verification Department of Homeland Security

    U.S. Citizenship and Immigration Services
    USCIS Form I-9

    OMB No. 1615-0047

    Expires 10/31/2022

    Section 2. Employer or Authorized Representative Review and Verification

    (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

    Identity and Employment Authorization

    Identity

    Employment Authorization

    Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

    (See instructions for exemptions)

    Section 3. Reverification and Rehires

    (To be completed and signed by employer or authorized representative.)

    C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

    I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

    Signature of Employer or Authorized Representative *