In Service Form 2024A Zoe GuFull Name 全名(必填) First Name 名 Last Name 姓 Date of Birth 出生日期(必填)Aide Code 護理員號碼(必填)SSN 工卡號嗎Address 地址 Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Waiving Health Coverage 放棄醫療保險(必填) I am covered under another group plan as a spouse or dependent 本人作為配偶或受撫養人得到其他團體醫療計劃保障 I am covered by Medicaid, Medicare, or Veterans Program 我現有醫療補助，聯邦醫療保險或退伍軍人計劃的保障 I am covered under a health insurance plan sponsored by second employer 我現有第二雇主所提供的醫療保險計劃的保護 I am covered through a non-group, individual or private health care plan not offered through my employer 我現有非團體, 個人或私人醫療保健計劃 I don't wish to participate in health care benefits at this time (I am declining health insurance entirely) 我目前不希望參加任何醫療保健福利（我完全拒絕了醫療保險）Initial 縮寫(必填)Signature 簽名(必填)HiddenAdministrative StuffHiddenRN Evaluator 名 姓 HiddenRN InitialHiddenLIC. NumberHiddenAide PositionHiddenHEP B Vaccination Yes, I accept vaccination No, I decline vaccinationEmailThis field is for validation purposes and should be left unchanged.
