Quick Hire Form
*You will need account information to set up Direct Deposit for your pay.
Contact Information
Name
*
First Name
Last Name
Personal Email Address
Phone Number
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Phone Number Type
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Home Address
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Street Address
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Personal Data
Driver's License or Personal ID Card
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ID Number
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Month
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Expiration Date
Social Security Number
*
Date of Birth
*
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Direct Deposit Information
I would like my paycheck paid by
*
Direct deposit to 1 bank account
Split direct deposit to 2 bank accounts
Amount Paid to Primary Bank Account
Direct Deposit Account 1
Direct Deposit Account 2
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Certification
What is your highest level EMS Certification?
*
I do not have an EMS Certification.
EMR
EMT
AEMT
Paramedic
EMS ID
*
Registry Number
*
Expiration Date
*
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Month
-
Day
Year
Date
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Emergency Contact
Contact's Name
First Name
Last Name
Relation
Contact's Phone Number
Please enter a valid phone number.
Contact's Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Company
Select all that apply.
I completed the online W-4.
I completed the online I-9.
I uploaded my I-9 personal identification documents.
I have not submitted any employment documents.
Company Identifier
*
EBS030521 - Elite Business Strategies, LLC
HES030521 - Healthcare Equity Solutions
LM3030521 - LM3 Solutions
TSD030521 - The Savvy Dimension, LLC
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Consent and Verification
My electronic signature verifies that all personal information entered on this form is true and correct to the best of my abilities.
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