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

Section 1 - Mailing address

Section 2 - Other Training: Certifications/Licenses

Section 3 - General Information

Section 4 - Employment Eligibility

Section 5 - Education

Section 6 - Current employer

Section 7 - Employment History

Section 8 - Reference 1

Section 9 - Reference 2

Section 10 - Reference 3

Section 11 - Emergency Contact Information

Section 12 - Additional information

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.