Pre-Employment Information - Pittsburgh #1 Home Care Agency

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PRE-Employment Information Form

Applicant Information:

Applicant First Name *

Applicant Last Name *

ALIAS if ever used

SSN

Applicant Phone *

Email Address *

Weight *

Hair Color *

Race *AsianBlackNative AmericanCaucasian/Latino

Ethnicity *Non-HispanicHispanic

County of Residence *

Country of Birth *

City of Birth *

State/Province of Birth *

Country of Citizenship *

Current Address (if different from Driver's License)

HHA eXchange Mobile ID

Have you lived in Pennsylvania for more than 2 years?YESNO

Please upload ONE of the following document as a proof of 2 years of residency.Motor vehicle records, such as a valid driver’s license or a State-issued identification. OR Housing records, such as mortgage records or rent receipts. OR Public utility records and receipts, such as electric bills. OR Local tax records. OR A completed and signed, Federal, State or local income tax return with the applicant’s name and address preprinted on it. OR Employment records, including records of unemployment compensation.

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Parent Information:

Parent Name *

Parent Age *

Additional Comments

Upload valid Driver License/ State ID and Social Security Card below:

Upload Driver License /State ID and SSN here.

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