Texas Quality One Medical Services Application

Personal Information
Applicant Name*

NombreMiddle NameApSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.

Email*
example@example.com
Birthdate*

MonthDayYear
Date
Social Security Number*
Gender*
Position you are applying for*
Put N/A if you do not have a client
Have you received the Covid-19 vaccination?*
*vaccination is not mandatory to work in Texas
Name of client you are applying for
What days are you available to work? (select all that apply)*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Have you ever been convicted of a felony*

YesNo
If yes, explain:*
Educational & Employment History
Name of High School/Secondary School attended*
Did you Graduate?*

YesNo
Name of College or University attended
Did you Graduate?

YesNo

Name of last or current employer*
What was your job title at your previous employer*
What is your last/current employer's phone number?*
Please enter a valid phone number.
When did you start working for your last/current employer?*

MonthDayYear
Date
When did you stop working for your last employer?

MonthDayYear
Date
What were/are your responsibilities at your last/current employer?*

Why did you leave your last employer?
Name of previous employer
What was your job title at your previous employer
What is your previous employer's phone number?
Please enter a valid phone number.
When did you start working for your previous employer?

MonthDayYear
Date
When did you stop working for your previous employer?

MonthDayYear
Date

What were your responsibilities at your previous employer?
Why did you leave your previous employer?
References

Please list three (3) references. We will contact some or all of them to discuss your qualifications.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*

Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship

PAYROLL DIRECT DEPOSIT FORM

We only pay through direct deposit
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Select the type of account*

Pre-paid Debit CardBank Checking Account
Account Number*
Routing Number*
Name of Bank or Institution*

CONSENT FOR CRIMINAL BACKGROUND CHECK, NURSE AIDE & EMPLOYEE MISCONDUCT REGISTRY
Birth Name*

First NameMiddle NameLast Name
Legal Name*

First NameMiddle NameLast Name
Alias*
If you don't have an alias type n/a
Race:*
Birthdate*

MonthDayYear
Date
Social Security Number*
Driver's License Number*
Signature of Applicant:*

Clear
Today's Date:*

MonthDayYear
Date

I, blanks* acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority for this agency to access an individual's criminal history data may be found in Texas Government Code 411; Subchapter F.
Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any mis-identification based on the result of the name and DOB search.
In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company.
Once this process is completed the information on my fingerprint criminal history record may be discussed with me.
Signature of Applicant or Employee *

Clear
Today's Date*

MonthDayYear
Date

Employee's Withholding Certificate. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

OMB No. 1545-0074
Click here to view paper form and instructions
Name*

First NameLast Name
Middle Initial
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Marital Status*

Single or Married filing separatelyMarried 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.)
(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
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
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
(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
(c) Extra withholding. Enter any additional tax you want withheld each pay period
Employee's signature: Under penalty of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete. (This form is not valid unless you sign it.)*

Clear
Date*

MonthDayYear
Date

Form 8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit

OMB No. 1545-1500
Click Here to view Form 8850 and its instructions.
Name

First NameLast Name
Social security number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Telephone number*
If you are under age 40, enter your date of birth (month, day, year)

MonthDayYear
Date
1.

Check here if you received a conditional certification from the state workforce agency (SWA) or an participating local agency for the work opportunity credit.
2. Check here if any of the following statements apply to you:

*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: a. Received SNAP benefits (food stamps) for the past 6 months; or b. 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.
3.

Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
4.

Check here if you are a veteran entitled to compensation for a service connected disability and you were discharged or released from active duty in the US Armed Forces during the past year.
5.

Check here if you are a veteran entitled to compensation for a service connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
6. Check here if you are a member of a family that:

*Received TANF payments for at least the past 18 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, ending 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.
7.

Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.
Job applicant's signature: 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.*

Clear
Date*

MonthDayYear
Date

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

USCISForm I-9OMB No. 1615-0047Expires 10/31/2022
Section 1

(Employees must complete and sign Section 1 of Form I-9 no laterthan the first day of employment, but not before accepting a job offer.)
Name*

First NameLast Name
Middle Initial
Other Last Names Used (if any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
U.S. Social Security Number*
Employee's E mail Address*
example@example.com
Employee's Telephone Number*
I attest, under penalty of perjury, that I am (check one of the following boxes):*

1. A citizen of the United States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident (Alien Registration Number/USCIS Number):4. An alien authorized to work until (continue below)
An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):

MonthDayYear
Some aliens may write "N/A" in the expiration date field.
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.
1. Alien Registration Number/USCIS Number:
2. OR Form I 94 Admission Number:
3. OR Foreign Passport Number:
Country of Issuance:
Signature of Employee*

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

MonthDayYear
Date
Preparer and/or Translator Certification (check one)

I did not use a preparer or translator.A preparer(s) and/or translator(s) assisted the employee in completing Section 1
Signature of Preparer or Translator

Clear
Name

First Name (Given Name)Last Name (Family Name)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I certify that my answers are true and complete to the best of my knowledge. Should this application lead to employment, I understand that false or misleading information in my application or interview may result in my termination.
Signature*

Clear
Date*

MonthDayYear
Date
PLEASE UPLOAD A COPY OF YOUR IDENTIFICATION AND SSN CARD*

Cancelof
Should be Empty:

Personal Information

Educational & Employment History

References

PAYROLL DIRECT DEPOSIT FORM

CONSENT FOR CRIMINAL BACKGROUND CHECK, NURSE AIDE & EMPLOYEE MISCONDUCT REGISTRY

Employee's Withholding Certificate. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Step 3: Claim Dependents

Step 4 (optional): Other Adjustments

Form 8850 Pre-Screening Notice and Certification Request for the Work Opportunity Credit

Individual Characteristics Form (ICF) Work Opportunity Tax Credit

Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services

Section 1