Forms

New Hire Requirements

1. Intern PA Credentialing Checklist 
   Please provide the document/items listed on the checklist for the processing of your employment application
2. House Staff Application 
   Write your name exactly as it appears on your Social Security Card.  It is important that you complete the application in its entirety.  If it does not apply to you please put N/A.
3. Copy of Diploma
4. Final Transcript
   1. Must be and original mailed from your school to the House Staff Office
   2. Must say DEGREE CONFERRED
5. Verification of Undergraduate Training
   Please send this form to the institution where you completed training.
6. Tax Forms (Federal and City/State) -- please return both forms even if you do not live in New York City or State
   1. W4
   2. IT-2104
7. I-9 Form
8. Licensure/Limited Permit
   1. For licensure application, please go to http://www.op.nysed.gov/
   2. Limited Permit Application
9. Jacobi Medical Center Forms
   1. JMC Application
   2. In-Service Education Profile
   3. Internet Policy & Usage
10. Pre Employment Physical Examination Form
11. Direct Deposit (DD) Enrollment Form
    1. Attach a voided check
    2. You may switch banks at any time
    3. Please note that not all will be on DD by July 1
       (If you do not have a social security number they will not put you on DD)
12. Uniform Order Forms
    1. Lab Coats
    2. Scrubs
13. CIS Form
    1. Fill out 1st box on page one
    2. Print and sign (in 3 places) on the 2nd page
    3. Please send back to House Staff for approval
14. Housing
15. Conflict of Interest Disclosure