TriDev - Healthcare & Medical

Employment Application

Please complete all information. An incomplete application may delay processing or disqualify you.

Position(s) applied for *

Please enter the position you're applying for

SSN *

Please enter your SSN

Last Name *

Please enter your last name

First Name *

Please enter your first name

Middle Initial

Address *

Please enter your address

City *

Please enter your city

State *

Please enter your state

Zip Code *

Please enter your zip code

Telephone Number Home

Telephone Number Work

Telephone Number Cell *

Please enter your cell phone number

E-Mail Address *

Please enter a valid email address

Date Of Birth *

Please enter your date of birth

Are you eighteen (18) years of age or older, can you provide proof of your eligibility to work? *

Yes

No

Please select an option

Employment History

List your complete employment history. Start with your current or last job.

Most Recent Employment

Employer *

Please enter employer name

Address *

Please enter employer address

Telephone Number *

Please enter telephone number

Starting Rate/Salary

Final Rate/Salary

Job Title *

Please enter job title

Supervisor Name/Title *

Please enter supervisor name/title

From Date *

Please enter start date

To Date *

Please enter end date

Work Performed (Include number & titles of any employees supervised) *

Please describe work performed

Reason For Leaving *

Please enter reason for leaving

You can add up to 3 previous employments

Education and Special Skills

Give dates and explain all periods of employment over last 10 years: *

Please explain your employment periods

Special skills and qualifications

List other activities which have provided you with experience, training or skills which you feel would be helpful in the position which you are applying:

Education

	High School/GED	Undergraduate College/University	Graduate/Professional
School Name & Location
Year Graduated
Diploma/Degree
Course of study (College & Graduate school only)
Describe any applicable training, apprenticeship or extra-curricular activities
Vocational School
State any additional educational information you feel may be helpful to us in considering your application

References (From Non-Relatives)

Give the name, address and telephone number of 4 references of persons with knowledge of your ability to perform the job

1)

Please provide at least one reference

2)

3)

4)

Criminal History Information

Tridev Health Care, LLC must consider an applicant's conviction record as it relates to job performance. A conviction record will not necessarily disqualify you from employment unless it would reasonably relate to the duties of the job.

Have you ever been convicted of a crime? *

Yes

No

Please select an option

Applicant's Statement

I certify that the answers given herein are true and complete to the best of my knowledge.

You must certify this statement

I hereby give Tridev Health Care, LLC the right to check all employment related references and to make a thorough investigation of my past employment, education, and activities. Tridev Health Care, LLC reserves the right to contact employment related references that may have information regarding your ability to do this job. I release from liability all persons companies and corporations supplying such information. I understand that any falsification, misrepresentation, or material omissions on this application may result in denial of employment or discharge.

You must authorize this investigation

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Tridev Health Care, LLC and myself for any term of employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that so such promise or guarantee is binding upon unless made in writing by the Manager or his/her authorized representative. Employee at Tridev Health Care, LLC are hired for indefinite terms of employment.

You must acknowledge these terms

Date *

Please enter the date

Drug Test Policy

Employees will be administered drug testing by a licensed facility if circumstances dictate. Drug test will be randomly assigned without notice by the management and will usually be scheduled during the employees regular shift.

Setting forth-good cause will be treated as a refusal to be tested. Good cause will be determined solely by management.
There is no amnesty date for past policy violations.
Employee will be paid at their regular rate while at the testing facility.

Refusal to be tested while scheduled or failure to appear for a schedules test without written permission will result in termination.

Date *

Please enter the date

Authorization to Release Information

Last Name *

Please enter your last name

First Name *

Please enter your first name

Middle Name

Current Address *

Please enter your current address

Dates Lived Here *

Please enter dates lived at current address

Addresses for the Past Seven Years (include street, city, state, zip code)

Date of Birth *

Please enter your date of birth

Other Names Used (including maiden name)

Years Used

Social Security Number *

Please enter your Social Security Number

Driver's License #

State

I hereby do ___ do not ___ authorize you to contact my current employer for Employment and Reference Verifications

I do hereby authorize verification of all information in my employment application from all sources of employment, education, motor vehicle, criminal history, personal character, and worker's compensation records in accordance with ADA, labor and wage records, etc. or any part thereof, and authorize any duly authorized agent of TDHC, LLC to obtain, whether the said records are public or private, and including those which may be deemed to be privileged or confidential in nature and I release all persons from liability on account of such disclosures.

Information appearing on this Authorization will be used exclusively by TDHC, LLC for identification purposes and for the release information which will be considered in determining any suitability for employment. I certify that I have made true, correct, and complete answers and statements on my employment application, any supplements to it and in any interview in the knowledge that they will be relied upon in considering my application for employment. I agree to provide additional information that may be requested to process my employment application. I authorize without reservation, any party or agency contacted by TDHC, LLC to furnish the above-mentioned information. This authorization is valid during the course of my employment to the extent permitted by law.

I have the right to make a request to TDHC, LLC, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which TDHC, LLC has previously furnished within the two year period preceding my request.

I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

Printed Name *

Please enter your printed name

Date *

Please enter the date

Direct Deposit Enrollment

To enroll in Full Service Direct Deposit, simply fill out this form. Attach a voided check for each checking account - not a deposit slip. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account.

Account Information

You may choose up to three accounts. Your last item must be for the remaining amount owed to you.

Account 1

Bank Name/City/State *

Please enter bank information

Routing/Transit # *

Please enter routing number

Account Number *

Please enter account number

Account Type *

Checking

Savings

Deposit Option *

$

Entire Net Amount

Account 2 (Optional)

Bank Name/City/State

Routing/Transit #

Account Number

Account Type

Checking

Savings

Deposit Option

$

Entire Net Amount

Account 3 (Optional)

Bank Name/City/State

Routing/Transit #

Account Number

Account Type

Checking

Savings

Deposit Option

$

Entire Net Amount

I hereby authorize my employer (hereinafter "Company") to deposit any amounts owed me by initiating credit entries to my accounts at the financial institutions (hereinafter "Bank") indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Company to my accounts. In the event that Company deposits funds erroneously into my account, I authorize Company to debit my account for an amount not to exceed the original amount of the erroneous credit.

This authorization is to remain in full force and effect until Company and Bank have received written notice from me of its termination in such time and in such manner as to afford Company and Bank reasonable opportunity to act on it.

Employee Name *

Please enter your name

Social Security # *

Please enter your SSN

Job Description Acknowledgment

Position Details

We are looking for Care Providers

By signing below, I acknowledge that I have read and understand the job description for the position I am applying for. I certify that I am able to perform these duties.

Date *

Please enter the date

Work Agreement and On-Call Policy

Work Agreement

TDHC is a Client first work environment. All staff excepting a position with TDHC, shall solemnly agree to put all Client's issues, care and support first over all other unscheduled unwarranted events. The owners and operators of "TDHC" hold our care and services of our Client's very high. We ask that any and all areas of services needed and warranted by the individuals receiving services, by this establishment, shall be met by all means of the staff/employee here of.

If agree, please sign.
If disagree, do not sign.

Print Name *

Please enter your printed name

Date *

Please enter the date

On Call and Emergencies

All staff of TDHC will be held to an "ON CALL" status. All staff will be willing to work in the case of an emergency situation.

If agree, please sign.
If disagree, do not sign.

Print Name *

Please enter your printed name

Date *

Please enter the date

Employment Eligibility Verification (Form I-9)

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.

Last Name (Family Name) *

Please enter your last name

First Name (Given Name) *

Please enter your first name

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name) *

Please enter your address

Apt. Number

City or Town *

Please enter your city

State *

Please enter state

ZIP Code *

Please enter ZIP code

Date of Birth (mm/dd/yyyy) *

Please enter your date of birth

U.S. Social Security Number *

Please enter your SSN

Employee's Email Address

I am aware that federal law provides for imprisonment and/or fines for false statements, or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box indicating my citizenship or immigration status, is true and correct.

Check one of the following boxes to attest to your citizenship or immigration status: *

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident (Enter USCIS or A-Number:)

4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

Please select your citizenship status

Today's Date (mm/dd/yyyy) *

Please enter today's date

Section 2. Employer Review and Verification

Employers or their authorized representative must complete and sign Section 2 within three business days of the employee's first day of employment.

List A

Document Title 1 Issuing Authority Document Number Expiration Date (if any)

List B

Document Title 1 Issuing Authority Document Number Expiration Date (if any)

List C

Document Title 1 Issuing Authority Document Number Expiration Date (if any)

Additional Information

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears 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.

First Day of Employment (mm/dd/yyyy)

Employer's Business or Organization Name

Employer's Business or Organization Address

Lists of Acceptable Documents

All documents containing an expiration date must be unexpired.

* Documents extended by the issuing authority are considered unexpired.

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

List A

Documents that Establish Both Identity and Employment Authorization

U.S. Passport or U.S. Passport Card
Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
Employment Authorization Document that contains a photograph (Form I-766)
For an individual temporarily authorized to work:
- a. Foreign passport; and
- b. Form I-94 or Form I-94A that has the following:
  1. The same name as the passport; and
  2. An endorsement of the individual's status or parole as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

List B

Documents that Establish Identity

Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
School ID card with a photograph
Voter's registration card
U.S. Military card or draft record
Military dependent's ID card
U.S. Coast Guard Merchant Mariner Card
Native American tribal document
Driver's license issued by a Canadian government authority

For persons under age 18 who are unable to present a document listed above:

School record or report card
Clinic, doctor, or hospital record
Day-care or nursery school record

List C

Documents that Establish Employment Authorization

A Social Security Account Number card, unless the card includes one of the following restrictions:
- (1) NOT VALID FOR EMPLOYMENT
- (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
- (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)
Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
Native American tribal document
U.S. Citizen ID Card (Form I-197)
Identification Card for Use of Resident Citizen in the United States (Form I-179)
Employment authorization document issued by the Department of Homeland Security

Acceptable Receipts

May be presented in lieu of a document listed above for a temporary period.

For receipt validity dates, see the M-274.

Receipt for a replacement of a lost, stolen, or damaged List A document
Receipt for a replacement of a lost, stolen, or damaged List B document
Receipt for a replacement of a lost, stolen, or damaged List C document
Form I-94 issued to a lawful permanent resident that contains an I-551 stamp and a photograph of the individual
Form I-94 with "RE" notation or refugee stamp issued to a refugee

Arizona Form A-4

Employee's Arizona Withholding Election

2024

Type or print your Full Name *

Please enter your full name

Your Social Security Number *

Please enter your SSN

Home Address - number and street or rural route *

Please enter your address

City or Town *

Please enter your city

State *

Please enter state

ZIP Code *

Please enter ZIP code

DATE

Please enter the date

Employee's Instructions

Arizona law requires your employer to withhold Arizona income tax from your wages for work done in Arizona. The amount withheld is a percentage of your gross taxable wages from every paycheck. You may also have your employer withhold an extra amount from each paycheck. Complete this form to select a percentage and any extra amount to be withheld from each paycheck.

What are my "Gross Taxable Wages"?

For withholding purposes, your "gross taxable wages" are the wages that will generally be in box 1 of your federal Form W-2. It is your gross wages less any pretax deductions, such as your share of health insurance premiums.

New Employees

Complete this form within the first five days of your employment to select an Arizona withholding percentage. You may also have your employer withhold an extra amount from each paycheck. If you do not give this form to your employer the department requires your employer to withhold 2.0% of your gross taxable wages.

Current Employees

If you want to change your current amount withheld, you must file this form to change the Arizona withholding percentage or to change the extra amount withheld.

What Should I do With Form A-4?

Give your completed Form A-4 to your employer.

Electing a Withholding Percentage of Zero

You may elect an Arizona withholding percentage of zero if you expect to have no Arizona income tax liability for the current year. Arizona tax liability is gross tax liability less any tax credits, such as the family tax credit, school tax credits, or credits for taxes paid to other states. If you make this election, your employer will not withhold Arizona income tax from your wages for payroll periods beginning after the date you file the form. To keep this election for the next calendar year, you must give your employer an updated Form A-4. If you do not, your employer may withhold Arizona income tax from your wages and salary until you submit an updated Form A-4.

Zero withholding does not relieve you from paying Arizona income taxes that might be due at the time you file your Arizona tax return. If you have an Arizona tax liability when you file your return or if at any time during the current year conditions change so that you expect to have a tax liability, you should promptly file a new Form A-4 and choose a withholding percentage that applies to you.

Voluntary Withholding Election by Certain Nonresident Employees

Compensation earned by nonresidents while physically working in Arizona for temporary periods is subject to Arizona income tax. However, under Arizona law, compensation paid to certain nonresident employees is not subject to Arizona income tax withholding. These nonresident employees need to review their situations and determine if they should elect to have Arizona income taxes withheld from their Arizona source compensation. Nonresident employees may request that their employer withhold Arizona income taxes by completing this form to elect Arizona income tax withholding.

Digital Signature *

Please provide your signature

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Care Providers

Job Description

List A

List B

List C

List A

List B

For persons under age 18 who are unable to present a document listed above:

List C

About Company

Services

Contact Us

14774 W Windrose Drive,

Phone: 772-607-0959, 623-330-3686

Email: info@tridevhealthcare.com