Date: 7/23/2014

Application Form

Synergy HomeCare Twin Cities South

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.

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 - General Information

Number Question Effective Date Expiration Date
1. Today's Date: (required)  
     
2. Job Type? (required)  
 
 
 
 
3. Can you provide documentation of a driver's license and auto insurance? (required)  
     
4. Drivers License Expiration Date:  
     
5. Auto Insurance Expiration Date:  
     
6. Gender  
 
 
7. How far are you willing to travel from your home to provide service in a client's home? (required)  
     
8. What hours and days are you available to work? (required)  
 
9. Are you willing to work short shifts (1-2 hours)? (required)  
     
10. Are you willing to work a 24-hour shift (required)  
     
11. Are you willing to work an overnight shift (required)  
     
12. Please provide a JOB REFERENCE NUMBER shown in our job posting (if Applicable).  
     
13. Please describe why you are interested in becoming a caregiver for Synergy including a description of your caregiving experience. (required)  
 
14. Do you have regular access to a computer/email? (required)  
     
15. How did you hear about Synergy HomeCare? (required)  
     

Section 2 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you a U.S. citizen? (required)  
     
2. If you are not a U.S. citizen, please indicate VISA type and number.  
     
3. Are you authorized to work in the U.S.? (required)  
 
 
 
 
4. Have you ever been convicted of, or plead guilty to or no contest to, a misdemeanor or felony in this state or any other (required)  
     
5. If Yes, please explain  
 
6. Are you 18 years of age or older? (required)  
     

Section 3 - Education

Number Question Effective Date Expiration Date
1. Name of High School: (required)  
     
2. Location of High School: (required)  
     
3. Did you graduate? (required)  
     
4. Years Attended (From/To): (required)  
     
5. Additional Education (vocational, undergraduate, etc.)  
     
6. If yes, please list the name of the school and years attended (From/To)  
 

Section 4 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1. Do you have any of the following certifications? (required)  
 
 
 
 
 
2. Do you have any of the following certifications? (required)  
 
 
 
3. Please list any other certifications you have:  
 
4. Please detail your experience (if any) working with Alzheimer's patients.  
 

Section 5 - Current Employment

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

Section 6 - Employment History

Number Question Effective Date Expiration Date
1. Last Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Describe Your Responsibilities:  
 
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving:  
 
14. May we contact?  
     

Section 7 - Employment History 2

Number Question Effective Date Expiration Date
1. Employer  
     
2. Address  
     
3. City  
     
4. State  
     
5. Zip Code  
     
6. Start Date  
     
7. End Date  
     
8. Position/Title  
     
9. Describe your responsibilities  
 
10. Supervisor's Name/Title  
     
11. Supervisor's Phone  
     
12. Reason for Leaving  
 
13. May we contact?  
     

Section 8 - Professional Reference #1

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Relationship to you:  
     
3. Phone:  
     

Section 9 - Professional Reference #2

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

Section 10 - 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)  
     



I certify that information contained in this application is true and complete. I understand that false information may 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.