Caregiver Application & Onboarding

Caregiver Application

Apply to Join CenterCare

Fields marked with * are required. This page collects onboarding data and supports printing/exporting a review packet.

HR compliance note: This online packet helps collect information for official forms, but CenterCare should still retain the signed official W-4, IT-2104, I-9, and CHRC documents according to applicable rules. I-9 Section 2 must be completed by the employer after document review.

1. Applicant Information

Legal name and contact details should match the employee’s government identification and tax documents.

First Name *

Middle Initial

Last Name *

Other Names / Aliases Used

Phone *

Email *

Street Address *

City *

State *

ZIP *

Date of Birth *

Social Security Number *

Gender

2. Employment & Availability

Position Type *

Availability *

Certification / License

Languages Spoken

Preferred Shifts

Morning Afternoon Evening Overnight

Relevant Experience

3. NYS DOH CHRC 102/103 Background Check Consent

For caregiver roles subject to the New York State Department of Health Criminal History Record Check process. Agency staff should confirm the exact current CHRC form and submission process before use.

Have you ever been convicted of a crime? *

Fingerprint Appointment Date

If yes, explain conviction(s), date(s), and disposition(s)

Address history for background check

I authorize CenterCare and/or the appropriate New York State Department of Health CHRC system user to submit my information for a criminal history record check, fingerprinting, and related employment eligibility review. *

Applicant E-Signature *

Date *

4. Federal W-4 Employee Withholding

Collects W-4 fields for payroll entry. Employee should review and sign the official IRS Form W-4.

Filing Status *

Single or married filing separately Married filing jointly or qualifying surviving spouse Head of household

Multiple jobs or spouse works

Step 3: Dependents amount ($)

Step 4(a): Other income ($)

Step 4(b): Deductions ($)

Step 4(c): Extra withholding each pay period ($)

Employee E-Signature *

Date *

5. New York IT-2104 Withholding

Used for New York State, New York City, and Yonkers withholding setup.

Total NYS allowances *

Additional NYS withholding ($)

Claim exempt?

NYC resident? *

Yonkers resident? *

Employee E-Signature *

Date *

6. I-9 Section 1 Employment Eligibility

Employee Section 1 only. Employer or authorized representative must complete Section 2 after examining acceptable documents.

Citizenship / Immigration Status *

U.S. citizen Noncitizen national of the United States Lawful permanent resident Alien authorized to work

USCIS / A-Number

Form I-94 Admission Number

Work authorization expiration date

Foreign Passport Number

Country of Issuance

Preparer / Translator Name, if used

I attest, under penalty of perjury, that the information I provided for employment eligibility verification is true and correct. *

Employee E-Signature *

Date *

7. Upload Supporting Documents

Upload completed official forms, certifications, IDs, work authorization documents, or other HR-requested records.

Upload FilesAccepted: PDF, Word, JPG, PNG. Do not send unencrypted sensitive files by regular email.

Additional Information

8. Review, Submit & Print Packet

Review the application packet before submission. The Print/Save PDF button uses your browser print dialog.

I certify that the information provided is complete and accurate to the best of my knowledge, and I authorize CenterCare to contact me about this application. *

Final Applicant E-Signature *

Date *

Application Summary

Complete the form to generate a summary.

Caregiver Application Packet

Apply to Join CenterCare

1. Applicant Information

2. Employment & Availability

3. NYS DOH CHRC 102/103 Background Check Consent

4. Federal W-4 Employee Withholding

5. New York IT-2104 Withholding

6. I-9 Section 1 Employment Eligibility

7. Upload Supporting Documents

8. Review, Submit & Print Packet

Application Summary

Application Packet Completed

Required Employment Documents

IRS Form W-4

NYS IT-2104

USCIS Form I-9

NYS DOH CHRC