85 Bartlett Street, Brooklyn, NY 11206 Fax: (718) 782-1538 www.whiteglovecare.com

Page 1 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE COMMUNITY CARE, INC.
Community Care Application
Registered Nurse/Licensed Practical Nurse
Thank you for your interest in White Glove Community Care. We are committed to make this home
health experience a rewarding one.
The following documentation must be completed and submitted, prior to your first assignment. We
therefore request that you, sign and return all documents in a timely manner. An online Home Health
test will be scheduled upon receipt of your completed application. The following documentation should
be submitted to our main office at 85 Bartlett Street, Brooklyn, NY.
1. White Glove Professional Profile
2. Resume/Record of employment
3. Current New York State Registration (Original to be presented in person.)
4. Evidence of current malpractice insurance in the amount of $1/3 million.
5. Curent BCLS certification.)
6.
Current clinical ANCC certifications (Home Health, Med Surg etc)
7. Documentation of annual attendance for mandatory education Fire Safety, Infection
Control, HIV Confidentiality/HIPAA Compliance, Abuse, and Patient Safety Goals.
8. Annual Physician's statement of satisfactory health, including: drug screens,
immunizations, Hepatitis B vaccine/waiver, neg PPD or chest x-ray.
9. Drivers license and evidence of auto insurance
10. W4 Form completed and signed.
11. I-9 Form Section 1 completed and signed.
12. Proof of eligibility to work in the U.S. or proof of citizenship Per I-9 Section 2.
(Must be presented in person to authorized White Glove representative).
13. Two professional references from previous employers (forms enclosed if needed)
14. Skills Assessment (forms enclosed or may be completed online)
15. Completed and signed White Glove Orientation checklist.
16. Competency testing scheduled with recruiter.
17. Job description signed copy
We greatly appreciate your taking the time to thoroughly complete the application requirements. Should
you have any difficulty in sending us your documents, we will gladly provide assistance. We will make
every effort provide for a rapid and uneventful employment process.
Page 2 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE COMMUNITY CARE, INC.
Community Care Professional Profile
Kindly check one: ‪ RN
‪ LPN
‪ NP
‪ Therapist
‪ Other_____________
___________________________________, _______________________________________
Last Name
First Name
Middle Name
______-_____-________
Social Security #
_________________________________________________________ ____________________, _______ ___________
Home Address
Apt. #
City
State
Zip Code
(_____)______-________(_____)______-______ _____−_____ (_____)______-_______
Home Phone #
Work Phone #
Shift on Duty
(_______)________-___________ ____________________________
Other #
E-Mail Address
Beeper/Cell #
____/______/_____
Date of Birth
In case of emergency notify:
___________________________________________________(______)_______-_________
Name, Relationship
Address
_____________ ______ _____/_____/_____
License #
State
Expiration Date
Current NY Drivers License?
Yes
No
Phone #
________________
Malpractice Co
Auto Insurance?
Yes
_____________ _____/_____/_____
Policy #
Expiration Date
No
Has your license or certification ever been investigated or suspended?
Yes
No
Has any malpractice claim or suit ever been brought against you?
Yes
No
Have you ever been convicted of a crime other than a minor traffic violation?
Yes
No
If any of above is yes, please give explanation indicating dates, circumstances and final outcome: _________________________
________________________________________________________________________________________________________
Specialty Experience
Home Health
yrs.
CHHA
LHCSA
Private Duty
Other
Long Term Care
yrs
Adult
Pediatric
Rehab Center
Other
Med Surg Acute
yrs
Adult
pediatric
Sub acute
Other
The statements made in this application are true to the best of my knowledge. I understand that any falsification will be the basis for
disqualification of employment or termination of services. I authorize White Glove Community Care, Inc. to verify the information I have
provided and to contact past employers and references concerning my ability, character and employment record. I release all such persons from
liability for furnishing said information. I authorize White Glove, as my employer, to release any medical and background information, which
may be relevant to my assignment to its client facilities. By submitting this application to White Glove, I authorize release of this information to
all other affiliates of the company and I acknowledge and agree that they may contact me using facsimile or any other means. Nothing contained
in this employment application, or in the granting of an interview, is intended to create an employment contract between White Glove and the
applicant for either employment or for providing of any benefit. All offers of employment are made conditional upon the applicant’s proving
employment eligibility and identity in accordance with the Immigration Reform and Control Act of 1986.
Signature__________________________________________________________ Date__/__/____
Page 3 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE COMMUNITY CARE, INC.
Employee Confidentiality Statement – HIPAA
As an employee of information at White Glove Community Care, Inc., assigned to a contracted facility/health
care organization, you may develop, use, or maintain patient records (for health care, quality improvement,
peer review, education, billing, reimbursement, administration, and research) or personnel records (for
employment, payroll, or other business purposes). Patient and personnel information from any source and in
any form, including paper record, oral communication, audio recording, and electronic display, is strictly
confidential. Access to confidential patient and personnel information is permitted only on a need-to-know
basis.
It is the policy of White Glove Community Care, Inc. and their contracting hospitals and health care
organizations that users (i.e., employees, medical staff, students, volunteers, and outside affiliates) shall
respect and preserve the privacy of confidentiality of patient and personnel information. Violations of this
policy include, but are not limited to:
•
•
•
•
•
•
Accessing information that is not within the scope of your job;
Misusing, disclosing without proper authorization, or altering patient or personnel information;
Disclosing to another person your sign-on code and password for accessing electronic or
computerized records;
Using another person’s sign-on code and password for accessing electronic or computerized records;
Leaving a secured application unattended while signed on; and
Attempting to access a secured application without proper authorization.
Violation of this policy by employees, staff, or volunteers may constitute grounds for corrective action up to
and including termination of employment or loss of practice privileges in accordance with White Glove and
the respective assigned contracting organization procedures and/or federal or state law. Violation of such
policies may constitute grounds for corrective action in accordance with applicable policies and procedures of
both White Glove Community Care, Inc., and the contracting organization.
I have read and agree to comply with the terms of the above statement and will read and comply with the
assigned hospital/health care organization’s policies and standards.
I further certify that I have received training and instruction on the confidentiality provisions of the Medical
Record Security and Privacy Regulations under the Health Insurance Portability and Accountability Act of
1996 (“HIPAA”) or any other applicable patient confidentiality laws.
Name: _________________________
(Please Print)
SS#:
_________________________
Signature: ______________________
Date___/___/____
Page 4 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE COMMUNITY CARE, INC.
Record of Employment
Name_____________________________________
Date _____/_____/_____
Give Present Employer First
Facility Name________________________________________________
Employed From__________ to__________
Address____________________________________________________
City___________________ State________
Title_______
Clinical Area/Unit________________
Travel assignment?
οYes
οNo
Average Patient Ratio________
Hours per Week_______
With which agency? _______________________
Supervisor_______________________________________
Phone # (_____)________-__________
Reason for Leaving___________________________________________________________________
Facility Name________________________________________________
Employed From__________ to__________
Address____________________________________________________
City___________________ State________
Title_______
Clinical Area/Unit________________
Travel assignment?
οYes
οNo
Average Patient Ratio________
Hours per Week_______
With which agency? _______________________
Supervisor_______________________________________
Phone # (_____)________-__________
Reason for Leaving___________________________________________________________________
Facility Name________________________________________________
Employed From__________ to__________
Address____________________________________________________
City___________________ State________
Title_______
Clinical Area/Unit________________
Travel assignment?
οYes
οNo
Average Patient Ratio________
Hours per Week_______
With which agency? _______________________
Supervisor_______________________________________
Phone # (_____)________-__________
Reason for Leaving___________________________________________________________________
Facility Name________________________________________________
Employed From__________ to__________
Address____________________________________________________
City___________________ State________
Title_______
Clinical Area/Unit________________
Travel assignment?
οYes
οNo
Average Patient Ratio________
Hours per Week_______
With which agency? _______________________
Supervisor_______________________________________
Phone # (_____)________-__________
Reason for Leaving___________________________________________________________________
Education
Name and Location of School
High School
__________________________________________________From ______-______ Degree______________
College
__________________________________________________From ______-______ Degree______________
Graduate
__________________________________________________From ______-______ Degree______________
School of Nursing__________________________________________________From ______-______ Degree______________
Page 5 9of
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
21
WHITE GLOVE COMMUNITY CARE, INC.
Physical Examination Report
NAME____________________________________________DATE OF PHYSICAL_________________________
ADDRESS_________________________________________SOCIAL SECURITY #________________________
HEIGHT__________ WEIGHT__________ B/P__________ DATE OF BIRTH ___________
________________________________________________________________________________________________
LABORATORY RESULTS
Tuberculin Test-PPD
nd
2 Step
Date Administered___________ Read___________
Results_______________________
Date_______________________________
Results______________________________
Chest X-Ray (attache report) Date_______________________________
Results______________________________
Rubella Titer
Rubeola Titer
Mumps Titer
Varicella Zoster
Immunization date: ___________________
Immunization date: ___________________
Immunization date: ___________________
Immunization date: ___________________
Titer Results: _________________________
Titer Results: _________________________
Titer Results: _________________________
Titer Results: _________________________
Tetanus & Dipthertia
Influenza Vaccine
H1N1 Influenza Vaccine
Date: ______________________________
Immunization Date: ______________________________
Immunization Date: ______________________________
If positive:
Drug Screening (attach lab report)
Date: ___________________ Results: _________________________
Hepatitis B Screening:
Vaccine #1_________Vaccine #2_________Vaccine #3_________
Titer: _________
Complete CBC
____________________ Urinalysis___________________ VDRL _______________
Are there any factors affecting your health which would place patients, their families or fellow employees at risk or which
would interfere with the performance of your job duties? These factors include, but are not limited to, habituation or active
addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter your behavior.
YES
NO
If yes, please describe. _____________________________________
______________________________________
Do you take any prescription drugs or medications regularly?
If yes, please describe usage, including dosage, frequency and purpose.
_____________________________________________________________
______________________________________________________________
Have you had any of the following:
Yes No
Yes No
[ ] [ ] Chest pain
[ ] [ ]Shortness of breath
[ ] [ ] Dizziness
[ ] [ ]Frequent headaches
[ ] [ ]Ringing in your ears
[ ] [ ]Double vision
[ ] [ ]Change in your voice
[ ] [ ]Chronic cough
[ ] [ ]Sore that does not heal
[ ] [ ]Drastic change in weight
[ ] [ ]Loss/gain of 20lbs/more
[ ] [ ]Recent change in your bowels
[ ] [ ]Back pain
[ ] [ ]Back injury-hospitalized
[ ] [ ]Surgery in the past 5 years
[ ] [ ]Hypertension
[ ] [ ]abetes
[ ] [ ]Allergies
Yes
[]
[]
[]
[]
[]
[]
[]
[]
[]
No
[ ]Ankle swelling
[ ]Unexplained stomach pain
[ ]Change in urination
[ ]Night sweats
[ ]GYN/GU problems
[ ]Blood in stool
[ ]Change in sleep patterns
[ ]Unexplained fatigue
[ ]Seizure condition
RECOMMENDATION
I CERTIFY THAT I HAVE EXAMINED THE ABOVE-NAMED INDIVIDUAL AND HAVE FOUND HIS/HER HEALTH TO BE SATISFACTORY TO WORK IN THE HEALTH
CARE FIELD.
PHYSICIAN’S SIGNATURE_______________________________________________ EXAM DATE____________________
PHYSICIAN’S NAME
(Please print or stamp)
ADDRESS
_______________________________________________ LICENSE#
_______________________________________________
TELEPHONE #
_______________________________________________
____________________
Page 6 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
TUBERCULOSIS SCREENING QUESTIONNAIRE
____________________________
Name
________________________
Date
Positive TB skin test (PPD) Date: ___________________________________
Last Chest X-Ray Date:____________________________________________
Please indicate if you are having any of the following problems for three to four weeks or longer:
1. Chronic Cough (greater than 3 weeks)
2. Production of Sputum
Yes______
Yes______
No_______
No_______
3.
Blood-Streaked Sputum
Yes______
No_______
4.
Unexplained Weight Loss
Yes______
No_______
5.
Fever
Yes______
No_______
6.
Fatigue/Tiredness
Yes______
No_______
7.
Night Sweats
Yes______
No_______
8.
Shortness of Breath
Yes______
No_______
NO EVIDENCE OF PULMONARY TUBERCULOSIS OR CONTAGIUM.
_________________
Date
_____________________________
Agency Employee Signature
Page 7 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE COMMUNITY CARE, INC.
Employee Hepatitis B Vaccine Waiver
OSHA Guidelines Advocate that Health Care Workers to Take Hepatitis B Vaccination.
This form is required only if you do
not wish to obtain the vaccination series.
I, ____________________________________(please print), have received information
regarding the transmission of Hepatitis B and understand the occupational risks and
OSHA guidelines as outlined.
I do however, decline the Hepatitis B vaccination at this time for the following reasons:
(PLEASE INDICATE BY PLACING A CHECKMARK BEFORE THE APPROPRIATE STATEMENT)
I have completed the vaccination series (See Physical Exam)
I have submitted titer reports, which document immunity (See Physical
Exam).
I have been advised by my physician not to receive vaccination for the
following reason(s) (Please state)
I have chosen to decline receiving the vaccine at this time. I understand that
by declining this vaccine, I continue to be at risk of acquiring Hepatitis B.
Employee Signature ___________________________
Date _____/_____/_____
Page 8 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE COMMUNITY CARE, INC.
Professional Employee Reference
PLEASE PRINT NAME AND ADDRESS
OF YOUR PREVIOUS EMPLOYER BELOW
Facility: _________________________________________
Address: _________________________________________
City: __________________State: _______Zip: __________
To: _____________________________________________
Tel: (
)
-_________________________
Fax: (
)
-_________________________
Dear Employer:
The following applicant has applied for employment with White Glove Community Care Home Health Program. Kindly provide the
requested information to verify employment and prior experience to the best of your ability. The furnished information will be held in
strict confidence and assist us in with the selection of qualified candidates. We do appreciate your time and thank you for your
assistance.
Print Name _____________________________________________________Social Security #: _______-_______-_________
Signature______________________________________________________
I Was Employed From _____/_____/_____To _____/_____/_____
Kindly Check One: RN
PLEASE
EVALUATE:
LPN
Experience
Verified
CNA
Clinical Area_______________________________
NT
Performance
Met standards
Other______________________
Performance
Did not meet
standards
Performance not
observed
KNOWLEDGE OF
Home Care
Regulations
KNOWLEDGE
MED/SURG
Nursing Practice
Assessment Skills
Care Planning
Technical skills
Communication
skills
ABILITY TO WORK
INDEPENDENTLY
ATTENDANCE &
RELIABILITY
ADDITIONAL COMMENTS:_(Overall Rating)___________________________________________________________________
REASON FOR LEAVING_(as applicable, if known)_____________________________________________________________________________
WOULD YOU CONSIDER APPLICANT FOR REHIRE?
YES
NO
SIGNATURE_____________________________________________ DATE ______/______/______
Print Name and Title___________________________________________________Facility _________________
Page 9 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE COMMUNITY CARE, INC.
Professional Employee Reference
PLEASE PRINT NAME AND ADDRESS
OF YOUR PREVIOUS EMPLOYER BELOW
Facility: _________________________________________
Address: _________________________________________
City: __________________State: _______Zip: __________
To: _____________________________________________
Tel: (
)
-_________________________
Fax: (
)
-_________________________
Dear Employer:
The following applicant has applied for employment with White Glove Community Care Home Health Program. Kindly provide the
requested information to verify employment and prior experience to the best of your ability. The furnished information will be held in
strict confidence and assist us in with the selection of qualified candidates. We do appreciate your time and thank you for your
assistance.
Print Name _____________________________________________________Social Security #: _______-_______-_________
Signature______________________________________________________
I Was Employed From _____/_____/_____To _____/_____/_____
Kindly Check One: RN
PLEASE
EVALUATE:
LPN
Experience
Verified
CNA
Clinical Area_______________________________
NT
Performance
Met standards
Other______________________
Performance
Did not meet
standards
Performance not
observed
KNOWLEDGE OF
Home Care
Regulations
KNOWLEDGE
MED/SURG
Nursing Practice
Assessment Skills
Care Planning
Technical skills
Communication
skills
ABILITY TO WORK
INDEPENDENTLY
ATTENDANCE &
RELIABILITY
ADDITIONAL COMMENTS:_(Overall Rating)___________________________________________________________________
REASON FOR LEAVING_(as applicable, if known)_____________________________________________________________________________
WOULD YOU CONSIDER APPLICANT FOR REHIRE?
YES
NO
SIGNATURE_____________________________________________ DATE ______/______/______
Print Name and Title___________________________________________________Facility _________________
Page 10 of 21
White Glove Community Care, Inc
85 Bartlett St, Brooklyn, NY 11206
Page 11 of 21
WHITE GLOVE COMMUNITY CARE, INC.
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax:Page
(718)12
782-1538
of 21
www.whiteglovecare.com
Page 13 of 21
WHITE GLOVE FCOMMUNITY CARE, INC.
Benefits & Policy
White Glove offers exciting incentives to nurses, primarily having the money available in your account – no
checks to cash.
♦ Direct Deposit – Money will be wired into any bank account you wish. Form enclosed.
♦ Access Advantage – You will receive an ATM card from White Glove’s bank (Bank of
America). You can release your payroll in cash from any ATM machine across the country. Request
an application from Mindy @ ext. #147.
♦ Annual Bonus/Vacation certificate – After working for one year, employees qualify to receive
a cash bonus. At your first anniversary with us, please call Raizy @ ext. #183 to receive your bonus.
♦ Pretax Metro Cards – White Glove can purchase for you a Transit Check Metro Card at greater
value from your pretax income. Request an application from Karen @ ext. #154.
♦ Dental Plan – The monthly premium for our Rayant Insurance Policy is as follows:
*Single
$48.67
*Employee and children
$94.54
*Employee and Spouse
$103.58
*Family
$150.92
Request an application from Faigy @ ext. #135.
♦ Health Insurance – The monthly premium for our Health Net Insurance Policy is as follows:
*Single
$343.19
*Employee and children
$634.93
*Employee and Spouse
$764.31
*Family
$1,021.63
Request an application from Faigy @ ext. #135.
It is our mission here at White Glove to help every nurse receive the maximum in rates, benefits and
employment opportunities. We will do everything in our ability to resolve any issue in a satisfactory
manner.
Good Luck, keep checking our new opportunities.
Looking forward to a productive relationship!
Payroll Policy:
Hours Worked:
Some clients allow nurses to work
only 40 hours. Others have a provision
for overtime. Hours worked over in
excess of 40 hours, with prior approval
from supervisor, will be paid at time
and a half.
Extra Hours at Shift:
In order to get paid for extra time
worked at shift, please indicate it
when signing out. Payment for those
hours will be subject to approval
from a supervisor.
Page 14 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
WHITE GLOVE FCOMMUNITY CARE, INC.
Authorization Agreement For Automatic Deposits (ACH Credits)
I (we) hereby authorize White Glove Community Care, Inc., hereinafter called COMPANY, to initiate credit
Entries and to initiate, if necessary, debit Entries and adjustments for any credit entries in error to my (our)
Checking Account Savings Account (select one) indicated below and the depository named below,
hereinafter called DEPOSITORY, to credit and/or debit the same to such account.
DEPOSITORY
NAME_________________________
BRANCH__________________________
CITY_________________________
STATE_____________ZIP____________
TRANSIT/ABA NO._____________
ACCOUNT NO.___________________
This authority is to remain in full force and effect until COMPANY has received written notification from me
(or either of us) of its termination in such time and in such manner as to afford COMPANY and
DEPOSITORY a reasonable opportunity to act on it.
NAME (S)_________________________________________
PLEASE PRINT)
SOCIAL SECURITY #: __ __ __-__ __-__ __ __ __
DATE_______________
Kindly place copy of check below:
SIGNED X____________________________
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
Page 15 of 21
WHITE GLOVE FCOMMUNITY CARE, INC.
•
•
•
•
•
•
Please fill-in the required information below.
When completed mail this original form with proper employment ID to the Payroll Department.
Your Access Advantage Account will be processed and your Fleet24 ATM card will be mailed to the designated address below.
If alternate address is provided all correspondence regarding this account, as well as the Fleet24 ATM card, will be mailed to the
alternate address.
Your Access Advantage Account and ATM card will become active once you have received notification that your pay has already been
deposited into your account.
If you have any questions regarding this application, please feel free to contact our Payroll Department.
YOUR NAME
MOTHER’S MAIDEN NAME
HOME ADDRESS (NO. AND STREET)
APT. #
CITY
STATE
ZIP
ALTERNATE ADRESS (NO. & STREET) ONLY IF CARD IS TO BE MAILED TO DIFFERENT ADDRESS THAN LISTED ABOVE.
CITY
STATE
SOCIAL SECURITY
DATE OF BIRTH
ZIP
HOME PHONE
BUSINESS PHONE
EMPLOYER
By signing below, I apply for a Fleet Access Advantage Account. I understand that I will receive a Fleet24 ATM card
and have access to withdraw cash, make balance inquiries, and perform point of sale transactions via Fleet24, NYCE®,
CIRRUS®, and Honor® ATMs (Customers who open their account in New Jersey can access the MAC® network). I
have received a copy of the bank’s addendum and a copy for the fee information sheet. I agree to be bound by the terms
of the sheet. Under penalties of perjury, I certify that:
1.
2.
The Social Security Identification Number shown above is my correct taxpayer identification number (or I am writing for a number to be issued),
and
I am not subject to backup withholding because; (a) I am exempt from backup and withholding, (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding.
Check if subject to backup withholding
Customer Signature______________________________________________ Date ______/_______/_______
BANK USE ONLY
BANK # ____________________
COST CTR _____
ACCT # _____________________________________________
DATE OPENED ____/____/____
85727D
RM # _____________
11/98 Non-Stock
MC2
Fleet Access Advantage Account Addendum
The rules and regulations of Fleet Personal Deposit Account Agreement except for the following will govern the Access Advantage Account:
1)
The Access Advantage Account can only be accessed through an ATM (automatic teller machine) of POS (point of sale) terminal. No checks or other items can be
drawn on the account. In an emergency, please contact your Fleet branch.
2)
Non-Fleet ATM transactions and POS purchases are limited to a combination or four per statement cycle, otherwise, the following fees apply:
Non-Fleet ATM withdrawal - $1.50
(Non-Fleet ATM transactions may be subject to other bank surcharge fees.)
Non-Fleet ATM Balance Inquiry - $1.50
POS Purchase - $.25
3)
Only funds electronically deposited by your employer will be accepted for deposit to the account.
4)
Access Advantage accounts may not be opened as joint accounts.
5)
If an Access Advantage Account remains inactive for 365 days with a zero balance, it will automatically close.
6) If at any time you would like to convert your Access Advantage Account to a traditional Fleet checking account, which would provide with additional features and
services, please contact you local branch.
Fee Schedule for Access Advantage
Overdraft charge (per item)
st
Statement Copy (1 3 pages)
Each additional page
Duplicate statement
Research (per hour)
Legal Processing
Abandoned Property
Protest fee
New fee amounts as of 7/1/99
CT
$22
$5
$1
$6
$30
$50
N/A
N/A
MA
$22
$5
$1
$6
$20
$50
N/A
N/A
Metro/LI
$30
$5
$1
$6
$20
$100
$25
$20
Other NY
$25
$5
$1
$5
$25
$100
$25
$15
NJ
$30
$5
$1
$6
$25
$100
$25
N/A
NH
$25*
$5
$1
$4
$20
$50
N/A
N/A
ME
$22*
$5
$1
$6
$20
$50
N/A
N/A
FL
$30*
$5
$1
$6
$30
$50
N/A
N/A
RI
22
$5
$1
$6
$15
$50
N/A
N/A
Page 16 of 21
PRINT CHARACTERS LIKE THIS
ABCDE 98765
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
Consent to Request Consumer Report & Investigative Consumer Report Information
Applicant's First Name or Initial
Last Name
I understand that White Glove Community Care (‘COMPANY’) will utilize the services of Sterling InfoSystems Inc., 249 West 17th
Street, New York, NY 10011, (800) 899-2272 to obtain a consumer report and/or investigative consumer report as part of the
procedure for processing my application for employment. I also understand that if my application for employment is granted, to the extent
permitted by law, COMPANY may obtain further information through subsequent investigations by STERLING so as to update, renew or extend
my employment.
I understand Sterling InfoSystems Inc. (“STERLING”) investigation may include obtaining information regarding my credit background,
bankruptcies, driving record, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support,
accounts placed for collection, and criminal record, subject to any limitations imposed by applicable federal and state law. I understand
such information may be obtained through direct or indirect contact with former employers, schools, financial institutions, landlords and
public agencies or other persons who may have such knowledge. If an investigative consumer report is being requested, I understand such
information may be obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates
or with others whom I am acquainted or who may have knowledge concerning my character, general reputation, personal characteristics or
standard of living.
I understand that I have the right to receive notice about the nature and scope of any investigative consumer report requested within five days
after the COMPANY receives my request or five days after the investigative consumer report was requested, whichever is later.
By checking the box, I indicate that I wish to receive further disclosure about the nature and scope of any COMPANY request for an
investigative consumer report.
I acknowledge that I have received the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any
related state summary of rights.
This consent will not affect my ability to question or dispute the accuracy of any information contained in my report. I understand if
COMPANY makes a conditional decision to disqualify me based all or in part on my report, I will be provided with a copy of the report and
another description in writing of my rights under the federal Fair Credit Reporting Act and, as required by law, any related state summary
of rights, and if I disagree with the accuracy of the purported disqualifying information in the report, I must notify COMPANY within five
business days of my receipt of the report that I am challenging the accuracy of such information with Sterling InfoSystems Inc.
I hereby consent to this investigation and authorize COMPANY to procure a consumer report(s) and/or investigative consumer report on
my background as stated above from a consumer reporting agency and/or investigative consumer reporting agency.
In order to verify my identity for the purposes of background identification, I am voluntarily releasing my date of birth, social security
number and the other information below for my own benefit and fully understand that all employment decisions are based on legitimate
non-discriminatory reasons.
Minnesota & Oklahoma Applicants Only: I have the right to request a copy of the consumer report obtained by COMPANY
from STERLING by checking the box. STERLING will mail the consumer report directly to me. I wish to receive a copy of the
consumer/investigative consumer report. (Check only if you wish to receive a copy.)
Maine Applicants Only: By checking the box, I indicate that I wish to receive the name, address and telephone number of the
nearest unit of the consumer reporting agency designated to handle inquiries regarding the investigative consumer report.
Washington State Applicants Only (AS APPLICABLE): I further understand that COMPANY will not obtain information about my
“credit worthiness, credit standing, or credit capacity” unless the information is required by law, or is substantially job related, and
the reasons for using the information are disclosed to me in writing. (If this option is checked, complete the question below.)
Reasons why COMPANY considers information about “credit worthiness, credit standing, or credit capacity” as substantially job
related:
_______________________________________________________________________________________
NY Applicants Only: I also acknowledge that I have received the attached copy of Article 23A of New York’s Correction Law. I further
understand that I may review and receive a copy of any investigative consumer report by contacting the consumer reporting agency. I
further understand that I will be advised if any further checks are requested and provided the name and address of the consumer reporting
agency.
_________________________________________________________________________
______________________
Signature
Today’s Date
Page 17 of 21
PRINT CHARACTERS LIKE THIS
ABCDE 98765
N
J
H
A
W H
I
T
E
G
L
O
V
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
E
For Office Use Only – Group ID (optional)
For Office Use Only – User ID (optional)
For Office Use Only – Location / Store # (optional)
First Name
Middle Name or Initial
Last Name
Date of Birth (MMDDYYYY)
Other Names Known By
Social Security Number
Male
Primary Telephone Number (no dashes)
Current Address
City
Female
Apt #
State
Previous Address
Zip Code
Apt #
City
State
Driver’s License Number (no dashes)
License State
#yrs at this address
#yrs at this address
Zip Code
Email Address
Signature
Today’s Date (MMDDYYYY)
Page 18 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
Para informacion en espanol, visite http://www.ftc.gov/credit o escribe a la FTC Consumer Response Center, Room 130-A 600
Pennsylvania Ave. N.W., Washington, D.C. 20580.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of
consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and
specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental
history records). Here is a summary of your major rights under the FCRA. For more information, including information
about additional rights, go to http://www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal
Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
•
You must be told if information in your file has been used against you. Anyone who uses a credit report or
another type of consumer report to deny your application for credit, insurance, or employment – or to take another
adverse action against you – must tell you, and must give you the name, address, and phone number of the agency
that provided the information.
•
You have the right to know what is in your file. You may request and obtain all the information about you in the
files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification,
which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a
free file disclosure if:
o
a person has taken adverse action against you because of information in your credit report;
o
you are the victim of identify theft and place a fraud alert in your file;
o
your file contains inaccurate information as a result of fraud;
o
you are on public assistance;
o
you are unemployed but expect to apply for employment within 60 days.
In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request
from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See
http://www.ftc.gov/credit for additional information.
•
You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness
based on information from credit bureaus. You may request a credit score from consumer reporting agencies that
create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some
mortgage transactions, you will receive credit score information for free from the mortgage lender.
•
You have the right to dispute incomplete or inaccurate information. If you identify information in your file that
is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless
your dispute is frivolous. See http://www.ftc.gov/credit for an explanation of dispute procedures.
•
Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information.
Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However,
a consumer reporting agency may continue to report information it has verified as accurate.
•
Consumer reporting agencies may not report outdated negative information. In most cases, a consumer
reporting agency may not report negative information that is more than seven years old, or bankruptcies that are
more than 10 years old.
•
Access to your file is limited. A consumer reporting agency may provide information about you only to people
with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business.
The FCRA specifies those with a valid need for access.
•
You must give your consent for reports to be provided to employers. A consumer-reporting agency may not
give out information about you to your employer, or a potential employer, without your written consent given to the
employer. Written consent generally is not required in the trucking industry. For more information, go to
www.ftc.gov/credit.
Page 19 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
You may limit “prescreened” offers of credit and insurance you get based on information in your credit report.
Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you
choose to remove your name and address from the lists these offers are based on. You may opt-out with the
nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).
•
You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer
reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in
state or federal court.
•
Identity theft victims and active duty military personnel have additional rights. For more information, visit
www.ftc.gov/credit.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you
may have more rights under state law. For more information, contact your state or local consumer protection
agency or your state Attorney General. Federal enforcers are:
FOR QUESTIONS OR CONCERNS REGARDING
PLEASE CONTACT
Consumer reporting agencies, creditors and others not
listed below
Federal Trade Commission
Consumer Response Center- FCRA
Washington, DC 20580 - 877-382-4357
National banks, federal branches/agencies of foreign
banks (word "National" or initials "N.A." appear in or
after bank's name)
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 - 800-613-6743
Federal Reserve System member banks (except
national banks, and federal branches/agencies of
foreign banks)
Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551 - 202-452-3693
Savings associations and federally chartered savings
banks (word "Federal" or initials "F.S.B." appear in
federal institution's name)
Office of Thrift Supervision
Consumer Programs
Washington D.C. 20552 - 800- 842-6929
Federal credit unions (words "Federal Credit Union"
appear in institution's name)
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 - 703-519-4600
State-chartered banks that are not members of the
Federal Reserve System
Federal Deposit Insurance Corporation
Division of Compliance & Consumer Affairs
Washington, DC 20429 - 877-275-3342
Air, surface, or rail common carriers regulated by
Department of Transportation
former Civil Aeronautics Board or Interstate Commerce Office of Financial Management
Commission
Washington, DC 20590 - 202-366-1306
Activities subject to the Packers and Stockyards Act,
1921
Department of Agriculture
Office of Deputy Administrator-GIPSA
Washington, DC 20250 - 202-720-7051
Page 20 of 21
New York Article 23-A Correction Law
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
§ 750. Definitions. For the purposes of this article, the following terms shall have the following meanings: (1) “Public
agency” means the state or any local subdivision thereof, or any state or local department, agency, board or
commission. (2) “Private employer” means any person, company, corporation, labor organization or association which
employs ten or more persons. (3) “Direct relationship” means that the nature of criminal conduct for which the person
was convicted has a direct bearing on his fitness or ability to perform one or more of the duties or responsibilities
necessarily related to the license, opportunity, or job in question. (4) “License” means any certificate, license, permit or
grant of permission required by the laws of this state, its political subdivisions or instrumentalities as a condition for the
lawful practice of any occupation, employment, trade, vocation, business, or profession. Provided, however, that
“license” shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire any
explosive, pistol, handgun, rifle, shotgun, or other firearm. (5) “Employment” means any occupation, vocation or
employment, or any form of vocational or educational training. Provided, however, that “employment” shall not, for the
purposes of this article, include membership in any law enforcement agency.
§ 751. Applicability. The provisions of this article shall apply to any application by any person for a license or
employment at any public or private employer, who has previously been convicted of one or more criminal offenses in
this state or in any other jurisdiction, and to any license or employment held by any person whose conviction of one or
more criminal offenses in this state or in any other jurisdiction preceded such employment or granting of a license,
except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not been removed by
an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be
construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with
an application for employment made by a prospective employee or previously made by a current employee.
§ 752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No
application for any license or employment, and no employment or license held by an individual, to which the provisions
of this article are applicable, shall be denied or acted upon adversely by reason of the individual’s having been
previously convicted of one or more criminal offenses, or by reason of a finding of lack of “good moral character” when
such finding is based upon the fact that the individual has previously been convicted of one or more criminal offenses,
unless:
(1) there is a direct relationship between one or more of the previous criminal offenses and the specific license or
employment sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an
unreasonable risk to property or to the safety or welfare of specific individuals or the general public.
§ 753. Factors to be considered concerning a previous criminal conviction; presumption. 1. In making a determination
pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall consider the
following factors: (a) The public policy of this state, as expressed in this act, to encourage the licensure and
employment of persons previously convicted of one or more criminal offenses. (b) The specific duties and
responsibilities necessarily related to the license or employment sought or held by the person. (c) The bearing, if any,
the criminal offense or offenses for which the person was previously convicted will have on his fitness or ability to
perform one or more such duties or responsibilities. (d) The time which has elapsed since the occurrence of the criminal
offense or offenses. (e) The age of the person at the time of occurrence of the criminal offense or offenses. (f) The
seriousness of the offense or offenses. (g) Any information produced by the person, or produced on his behalf, in
regard to his rehabilitation and good conduct. (h) The legitimate interest of the public agency or private employer in
protecting property, and the safety and welfare of specific individuals or the general public. 2. In making a determination
pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall also give
consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which
certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.
§ 754. Written statement upon denial of license or employment. At the request of any person previously convicted of
one or more criminal offenses who has been denied a license or employment, a public agency or private employer shall
provide, within thirty days of a request, a written statement setting forth the reasons for such denial.
§ 755. Enforcement. 1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a
proceeding brought pursuant to article seventy-eight of the civil practice law and rules. 2. In relation to actions by
private employers, the provisions of this article shall be enforceable by the division of human rights pursuant to the
powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city
commission on human rights.
Page 2 of 21
85 Bartlett Street, Brooklyn, NY 11206
Phone: (718) 387-8181, (866) 387-8100
Fax: (718) 782-1538
www.whiteglovecare.com
VOLUNTARY SELF-IDENTIFICATION FOR EMPLOYMENT APPLICANT
We have received and appreciate your expression of interest in employment with White Glove. White Glove is committed to a
policy of equal opportunity in accordance with all Equal Opportunity/Affirmative Action laws and regulations. For federal record
keeping purposes, White Glove is required to gather and maintain certain information on individuals who apply for employment
with us. The information you provide below will not be used to make any employment-related decisions. The information you
provide below is voluntary, and refusal to provide this information will not result in any adverse treatment.
Regardless of whether you provide the gender and race/ethnic group information, please enter your name in the space provided
below, enter the position for which you applied and the date you applied for that position.
Please check the categories which apply to you:
GENDER INFORMATION:
Male
Female
ETHNIC GROUP/RACE INFORMATION:
Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin regardless of race.)
Yes
No
If you answer “No”, please check all that apply to you:
White (Not Hispanic or Latino) – A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa.
Black or African American (Not Hispanic or Latino) – A person having origins in any of the black racial groups of Africa.
Asian (Not Hispanic or Latino) – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,
Thailand and Vietnam.
Native Hawaiian or Other Pacific Island (Not Hispanic or Latino) – A person having origins in any of the peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
American Indian or Alaskan Native (Not Hispanic or Latino) – A person having origins in any of the original peoples of North
or South America (including Central America), and who maintain tribal affiliation or community attachment.
*********************************************************************************************
I do not wish to Self-Identify
Name: _________________________________________ Date: _____________________________________
Position Applied For:
__________________________________________