New Hire Intake

New Hire Intake Form

Division*

Employee Name*

First

Last

Email address*

Cell Phone Number*

Home Street Address*

Home City*

Home State*

Home Zip Code*

Employment Status*

Discipline*

Title*

Is there a set start date?*

Start Date*

Start Time*

Facility Name*

Hourly Rate*

Weekly Hours*

Enrolling in Medical?*

Yes

No

Not Eligible

Unknown

Is New Hire A:

Current Per Diem

Rehire

Receiving Sign on Bonus?*

Yes

No

Amount of Sign on Bonus*

Payment Terms*

Contract Length*

Receiving COBRA Coverage?*

Yes

No

Monthly Amount of COBRA*

Number of Months Covered*

Comments

Submitted By*

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CORPORATE HEADQUARTERS

400 nj-70
lakewood, new jersey 08701
phone: 888-400-rehab (7342)