NEW EMPLOYEE ENROLLMENT INSTRUCTIONS

CDS Attendant Application Complete application entirely, sign, and date.

Form W-4 At a minimum, complete lines 1-7. Sign and date the form (under line 7).

Form MO W-4 Complete the Employee section. Sign and date in the Signature section.

USCIS Form I-9 Complete Section 1. Employee Information and Attestation.

Under Section 1, check one of the four options.

Leave the Preparer and/or Translator Certification section blank.

Leave the back side of the form blank.

Review the third page. To prove you are eligible to work in the United States, you must provide

adequate documentation. NEILS staff must physically see either one document from List A OR one

document from List B AND one document from List C and record information from the documents onto

the I-9 Form. (For example, if I do not have any of the items from List A, then I must provide an item

nse from List B and a Social Security Card from List C.) It is

the first three days of employment, per USCIS requirements. Attendants are encouraged to be present

documents at the time. If you are not able to be present, you must bring the I-9 form and eligible

working through the Consumer Directed Services program.

Worker Registration Form Go to https://webapp03.dhss.mo.gov/fcsrnet/ to check if you are already registered with the Family Care Safety

Registry (for your background screening). Type in your Social Security Number and the security text (case

sensitive) and click submit.

If it states that your social security number WAS found, you do not have to complete this Worker

Registration Form or pay for a background screening.

If it states that your social security number was NOT found, you must complete the Worker

Registration Form.

a. To complete the form, enter your social security number, all personal information, and your

contact information. Leave the Employer section blank. Sign and date the form at the bottom. b. The fee for processing is $_________ as established by the Missouri Family Care Safety Registry

(which includes both a one-time registration fee and online processing fee). This fee must be

paid by cash or money order (made payable to NEILS).

https://webapp03.dhss.mo.gov/fcsrnet/

Attendant Care Contract Read entirely. Complete Lines A, B, and C on page 1. Employee (you) and the Employer (the consumer

you work for) just sign the contract on the last page.

Direct Deposit Form Complete top section. (Employer name is the person you work for)

All attendants are required to enroll in Direct Deposit. Payroll can be deposited to a checking account,

savings account, Rapid! Paycard, or any other account or paycard that will allow direct deposit.

If you already have an account or paycard, check the account where you want your payroll to be

deposited to. Write in your account number, the bank name, and bank routing number. Attach a

voided check or official letter from your bank that includes your name, the account name, account

number, and bank routing number.

If you do not have an account or paycard, you may enroll with Rapid! Paycard by simply checking the

Rapid! Paycard box (leave the account # blank). NEILS will issue you a Rapid! Paycard and mail it to you

along with card information.

o Go to http://www.rapidpaycard.com/cardholder-info for additional information.

Attendant Pay Schedule Keep for your records to follow along with the pay schedule.

Wage Range Form TO BE COMPLETED BY EMPLOYER ONLY!!!

OTHER IMPORTANT INFORMATION

The consumer you work for is your employer. NEILS is NOT your employer. Any paperwork that is

submitted by your employer to NEILS with NEILS listed as the employer will be rejected.

Any payroll issues or concerns must be addressed through your employer. Your employer must be the

one to call NEILS if there is an issue or a concern.

If you need an employment verification completed, these forms may be dropped off, mailed, or faxed

to NEILS. However, the employment verification will be not accepted or processed if the wrong

employer is listed. Make sure that you put the consumer you work for as your employer. NEILS is not

your employer.

Address for employment verifications: NorthEast Independent Living Services

Employment Verifications

909 Broadway, Suite 350

Hannibal, MO 63401

Fax number for employment verifications: 573-221-9445

http://www.rapidpaycard.com/cardholder-info

CDS Attendant Application

Applicant Name (Full): _________________________________ SS#: _____ - ____ - _____

List any additional aliases and/or Social Security numbers used: _____________________________

Physical Address: ________________________ Mailing Address: _______________________ Street Street

________________________ _______________________

City, State, Zip City, State, Zip

Home phone: ___________________________ Cell Phone: ___________________________

Email Address: __________________________

Are you at least 18 years old? Yes No

Do you have any criminal convictions, findings of guilt, pleas of guilty, and/or pleas of nolo contendere except minor traffic violations?

If yes, explain:

Yes

No

Have you ever been listed on the Employee Disqualification List?

If yes, why?

Yes No

Have you ever applied for a Good Cause Waiver? If yes, when and why?

Yes No

Are you registered with the Family Care Safety Registry? Yes No Do you have regular access to reliable transportation? Yes No

Are you available and/or willing to come in with short notice or be on-call? Yes No

List any certifications or licenses you have: List days/hours of weekly availability:

Sunday Thursday Monday Friday

Tuesday Saturday Wednesday

_____ Bathing _____ Dressing _____ Grooming _____ Ostomy or Cath. Care

_____ Bowel routine _____ Bladder routine _____ Toileting assistance _____ Transfer Devices

_____ Passive range of motion _____ Medication reminders _____ Turning/positioning _____ Treatments

_____ Equipment Maintenance _____ House cleaning _____ Laundry On site _____ Laundry Off site

_____ Take out trash _____ Essent. Correspondence _____ Meal preparation _____ Shopping/Errands

Employment History

List the last 5 years of employment with most recent first. If you were previously an attendant

employed by an individual receiving Consumer-Directed Services, list them as the company.

Company Name Supervisor Name Date Employed From_________ to __________ Position/Title Address

Phone Number Reason for leaving Duties May I contact? ___ Yes ___ No

Company Name Supervisor Name Date Employed From_________ to __________ Position/Title Address Phone Number Reason for leaving Duties May I contact? ___ Yes ___ No

Company Name Supervisor Name Date Employed From_________ to __________ Position/Title Address Phone Number Reason for leaving Duties May I contact? ___ Yes ___ No

References

Please list three credible references NOT related to you.

Name Relationship Phone Number Address

Name Relationship Phone Number Address

Name Relationship Phone Number Address

I certify the answers herein are true and accurate to the best of my knowledge and I hereby authorize performance of pre-

employment criminal record checks for employment purposes only. I hereby give consent to performance of a closed

records check pursuant to the Section 610.120 RSMo. I understand any employment is conditioned on my consent to

such checks as well as the findings/results of such checks. I hereby release my Employer and his/her fiscal agent

conducting such background checks and/or furnishing such criminal record information from any and all liability arising out

of the conducting of a check or the furnishing or receipt of criminal record information. My Employer and/or his/her fiscal

agent may rely on a copy of this release. In the event of employment, I understand that false or misleading information

given on this application or in interview(s) may result in refusal to hire or, if employed, may result in discharge after its

discovery. I further understand that all qualified applicants will be considered without regard to race, gender, religion,

veteran status, disability, age, sexual orientation, national origin, or any other classification protected by law.

Signature of Applicant: ________________________________________ Date: __________________