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Employer's name

Telephone no

EIN

Street address

City or town, state, and ZIP code

Person to contact, if different from above

Telephone no

Street address

City or town, state, and ZIP code

If, based on the individual's age and home address, he or she is a member of group 4 or 6 (as described under Members of Targeted Groups in the separate instructions), enter that group number (4 or 6)

Date applicant:

Gave information

Was offered job

Was hired

Started job

have read and understood A1. Omega Healthcare services policy on Abuse and Neglect. I agree to abide by this policy. I understand that not abiding to this policy could result in disciplinary action Including termination of contractual employment and reporting to regulatory authorities.

Employee signature

Date

Agency representation

Date

Post-Hire Form

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Date applicant:

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