Date: 9/19/2014

Application Form

Synergy HomeCare of San Diego

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Fill out as many fields as you can in this form. You can provide any additional information you deem useful at the end of the form. Thank you. 

 

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Mailing address

Number Question Effective Date Expiration Date
1 Mailing Address (required)  
     

Section 2 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1 CPR Certification  
 
2 First Aid Certification  
 
3 Tuberculosis Test  
 
4 PCA certification  
 
5 CNA certification  
 
6 HHA certification  
 
7 Other Certifications/Licenses? Please list here: (required)  
 
8 Languages spoken (required)  
     

Section 3 - General Information

Number Question Effective Date Expiration Date
1 Are you applying for Adult Care, or Child Care, or both? (required)  
     
2 Have you been fingerprinted recently? (required)  
     
3 Are you Trustline Certified?  
     
4 Date Available? (required)  
     
5 Job Type? (required)  
 
 
 
 
6 What type of shift can you do (daytime, night shifts, 24 hour live-in, etc...)? (required)  
 
7 Mailing address  
     
8 Best time/day and phone number to reach you  
     
9 Do you have a reliable means of transportation? (required)  
     
10 Can you provide documentation of a driver's license and auto insurance? (required)  
     
11 Valid CA Drivers License #:  
   
12 Auto Insurance:  
   
13 Have you ever applied at Synergy HomeCare? (required)  
     
14 If yes, where?  
     
15 Have you ever worked for Synergy HomeCare? (required)  
     
16 Has your professional license or certification ever been investigated or suspended? (required)  
     
17 If yes, please explain:  
 
18 Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
19 If yes, please explain:  
 
20 Have you ever been named as a defendant in a professional liability action? (required)  
     
21 If yes, please explain:  
 
22 Have you ever been released from a job due to discipline or being fired? (required)  
     
23 If yes, please explain:  
 
24 Would you consent to a drug test at the client's request? (required)  
     
25 Any objection to travel if required by the position? (required)  
     
26 Any objection to occasional overtime? (required)  
     
27 Please list any reason why you might be unable to perform consistently and promptly any of the job duties  
 
28 Other names or aliases under which you have been employed  
     

Section 4 - Employment Eligibility

Number Question Effective Date Expiration Date
1 Are you a U.S. citizen? (required)  
     
2 If you will be employed on a visa, please specify type of visa  
     
3 Are you authorized to work in the U.S.? (required)  
 
 
 
 

Section 5 - Education

Number Question Effective Date Expiration Date
1. Name of College:  
     
2. Location of College:  
     
3. Month/Year Graduated:  
     
4. Diplomas, Degrees Received:  
     
5. Additional Education (vocational, undergraduate, etc.)  
     
6. If yes, please list the name of the school and years attended (From/To)  
 

Section 6 - Current employer

Number Question Effective Date Expiration Date
1. Facility / Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date  
     
8. Starting Salary:  
     
9. Current Salary:  
     
10. Position/Title:  
     
11. Describe Your Responsibilities:  
 
12. Specialty:  
     
13. Supervisor's Name/Title:  
     
14. Supervisor's Phone:  
     
15. May we contact?  
     
16. Reason for leaving  
 

Section 7 - Employment History

Number Question Effective Date Expiration Date
1 Facility/Employer: (required)  
     
2 Address:  
     
3 City:  
     
4 State:  
     
5 Zip Code:  
     
6 Start Date:  
     
7 End Date:  
     
8 Starting Salary:  
     
9 Ending Salary:  
     
10 Position/Title:  
     
11 Describe Your Responsibilities:  
 
12 Specialty:  
     
13 Supervisor's Name/Title:  
     
14 Supervisor's Phone:  
     
15 May we contact?  
     
16 Reason for Leaving:  
 
17 Please indicate all other employments for the past ten (10) years: name of employer, address and phone number, start date, end date, position and duties  
 
18 Please indicate reasons for periods you were unemployed  
 
29 How many years of experience with adult care? (required)  
     
30 How many years of experience with child care? (required)  
     

Section 8 - Reference 1

Number Question Effective Date Expiration Date
1. Name:  
     
2. Relationship:  
     
3. Phone:  
     

Section 9 - Reference 2

Number Question Effective Date Expiration Date
1. Name:  
     
2. Relationship:  
     
3. Phone:  
     

Section 10 - Reference 3

Number Question Effective Date Expiration Date
1. Name:  
     
2. Relationship:  
     
3. Phone:  
     

Section 11 - Emergency Contact Information

Number Question Effective Date Expiration Date
1. First Name: (required)  
     
2. Last Name: (required)  
     
3. Address:  
     
4. City:  
     
5. State:  
     
6. Zip Code:  
     
7. Phone 1: (required)  
     
8. Phone 2:  
     
9. Relationship: (required)  
     

Section 12 - Additional information

Number Question Effective Date Expiration Date
1 Any additional information you want to share with us? Add it here. You can also copy and paste your resume here.  
 



I hereby certify that the answers given by me to all of the questions contained on this application form are true and complete to the best of my knowledge. If employed by Synergy HomeCare, I will comply with all rules and regulations of the company. I agree to submit to a physical and or drug examination if required. I also authorize my former employers to give any information they have regarding me to Synergy HomeCare, whether or not it is on their records. I authorize Synergy HomeCare to conduct any background checks necessary including, but not limited to: Felony and Misdemeanor convictions, previous arrest history, and driving records (DMV). I hereby release Synergy HomeCare from all liability for and damage whatsoever for issuing the same. I understand that if any fraudulent information is given on this application, it will be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above. Synergy HomeCare is an Equal Opportunity Employer. I understand that job positions are placed equally without discrimination because of race, creed, color, religion, sex, national origin, sexual preference, handicap, or age.