Date: 4/18/2014

Application Form

Synergy HomeCare of Sun City
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 - Personal Information

Number Question Effective Date Expiration Date
1 Social Security #: (required)  
  (Numeric Answer Only)    
2 Date available for work? (required)  
     
3 Person to notify in case of emergency (name/relationship/ phone)? (required)  
     
4 How did you learn about Synergy HomeCare? (required)  
     
5 Have you ever applied at Synergy HomeCare? If so, where? (required)  
     
6 Do you have a reliable means of transportation? (required)  
     
7 Are you covered by auto liability insurance? (required)  
     
8 Can you submit verification of your legal right to work in the U.S.? (required)  
     
9 If you will be employed on a visa, please specify type of work visa:  
     
10 If you read/speak/write another language, please describe:  
     
11 Other names/aliases under which you have been employed?  
     
12 Have you ever been convicted of a felony? (required)  
     
13 Have you ever been named as a defendant in a professional liability action? (required)  
     
14 Have you ever been released from a job due to discipline or being fired? (required)  
     
15 Would you consent to a drug test if requested? (required)  
     
16 Do you take any illegal drugs or medications which have not been prescribed for you? (required)  
     
17 Are you physically able to perform essential functions of the job as per the job description, with or without a reasonable accommodation? (See Section 6) (required)  
     
18 Can you get a client to do what is good for them by gentle persuasion? (required)  
     
19 Are you a team player? (required)  
     

Section 2 - Certifications

Number Question Effective Date Expiration Date
1 Is your CPR certification current? (required)  
   
2 Is your First Aid certification current? (required)  
   
3 Have you been tested for TB (tuberculosis) within the past year? (required)  
   

Section 3 - Licenses

Number Question Effective Date Expiration Date
1 Do you hold any state licenses/certifications (CNA, certified caregiver, RN, MA, etc) Please list credential(s) and State(s)?  
     
2 Has your professional license or certification ever been investigated or suspended? If yes, please explain  
     

Section 4 - Education

Number Question Effective Date Expiration Date
1 College (name/location)  
     
2 Month/Year Graduated?  
     
3 Diplomas, Degrees Received?  
     
4 Other School (name/location)  
     
5 Month/Year graduated?  
     
6 Diplomas, Degrees Received?  
     

Section 5 - Experience

Number Question Effective Date Expiration Date
1 **PLEASE NOTE – You must accurately complete the information about your skills, lifting limits and availability. If any of these or other information on your application is not true and complete, it will be grounds for termination of the hiring process and/or could result in immediate dismissal.** (required)  
 
2 Indicate years of experience: Dementia?  
  (Numeric Answer Only)    
3 Indicate years of experience: Cancer?  
  (Numeric Answer Only)    
4 Indicate years of experience: Stroke?  
  (Numeric Answer Only)    
5 Indicate years of experience: Heart patients?  
  (Numeric Answer Only)    
6 Indicate years of experience: Quadriplegic  
  (Numeric Answer Only)    
7 Indicate years of experience: Paraplegic?  
  (Numeric Answer Only)    
8 Indicate years of experience: Terminal patients?  
  (Numeric Answer Only)    
9 Indicate years of experience: HIV?  
  (Numeric Answer Only)    
10 Indicate years of experience: Diabetic?  
  (Numeric Answer Only)    
11 Indicate years of experience: other?  
  (Numeric Answer Only)    
12 Indicate years of experience: Alzheimers?  
  (Numeric Answer Only)    

Section 6 - Skills:

Number Question Effective Date Expiration Date
1 Work with Alzheimer's/Dementia? (required)  
     
2 Work with Hoyer Lift? (required)  
     
3 Work with Transferring/Lifting client (no more than 25 lbs.)? (required)  
     
4 Empty catheter bag if needed? (required)  
     
5 Know how to put on and use a Gait belt? (required)  
     
6 Work with females? (required)  
     
7 Work with males? (required)  
     
8 Perform bath/shower assist or standby? (required)  
     
9 Shampoo? (required)  
     
10 Perform bed bath? (required)  
     
11 Dressing assist? (required)  
     
12 General housekeeping - dusting, sweep & mop? (required)  
     
13 Do laundry? (required)  
     
14 Do ironing? (required)  
     
15 Change linens, make beds? (required)  
     
16 Clean bathroom/bedroom/kitchen? (required)  
     
17 Empty commode, if there is one? (required)  
     
18 Perform errands, i.e. grocery shopping? (required)  
     
19 Meal preparation? (required)  
     
20 Working with incontinence? (required)  
     
21 Walk assist? (required)  
     
22 Empty trash? (required)  
     

Section 7 - Environment:

Number Question Effective Date Expiration Date
1 Work with cats? (required)  
     
2 Work with small dogs? (required)  
     
3 Work with large dogs? (required)  
     
7 Willing/able to drive own car? (required)  
     
8 Willing/able to drive Client's Car? (required)  
     
9 Are you a smoker? (required)  
     
10 Work with smoker? (required)  
     

Section 8 - Hours available to work - put start/end times

Number Question Effective Date Expiration Date
1 Monday? (required)  
     
2 Tuesday? (required)  
     
3 Wednesday? (required)  
     
4 Thursday? (required)  
     
5 Friday? (required)  
     
6 Saturday? (required)  
     
7 Sunday? (required)  
     
8 Are you willing to work overnights? (required)  
     
9 Are you willing to live in? (required)  
     

Section 9 - Areas willing to work?

Number Question Effective Date Expiration Date
1 Deer Valley, El Mirage, Glendale, North Phoenix, Peoria, Sun City, Sun City West, Surprise, West Phoenix, Wickenburg, Youngtown, Wittmann (required)  
 

Section 10 - Employment History - current to past employers?

Number Question Effective Date Expiration Date
1 Are you currently employed? If so, where? (required)  
     
2 Facility/Employer: (required)  
     
2 May we contact your current employer? (required)  
     
3 Address (street/city/state/zip) (required)  
     
4 Dates employed from and to: (required)  
     
5 Position held (required)  
     
6 Supervisor's name and phone # (required)  
     
7 Starting and ending salary: (required)  
     
8 Summary of job duties: (required)  
     
9 Reason for leaving, if applicable:  
     
10 Facility/Employer: (required)  
     
11 Address (Street,City,State,Zip Code): (required)  
     
12 Dates employed From and To: (required)  
     
13 Position held? (required)  
     
14 Supervisor's name and phone # (required)  
     
15 Starting/Ending Salary? (required)  
     
16 Summary of job duties: (required)  
     
17 Reason for leaving, if applicable:  
     
18 Facility/Employer:  
     
19 Address (Street,City,State,Zip Code):  
     
20 Dates employed From and To:  
     
21 Position held?  
     
22 Supervisor's name and phone #  
     
23 Starting/Ending Salary?  
     
24 Summary of job duties:  
     
25 Reason for leaving, if applicable:  
     

Section 11 - General Questions

Number Question Effective Date Expiration Date
1 Do you think that any time whatsoever it might be acceptable to walk away from a job and leave a client unattended? (required)  
     
2 Do you understand the negativity of some clients may be a part of their illness and that they deserve your love and kindness anyway? (required)  
     
3 Are you able to outwardly express real tenderness and caring for a client? (required)  
     
4 When you are working with a client, whose needs should come first? (required)  
     
6 How important is a well-groomed appearance on your part? (required)  
     
7 When working in someone's home, who would be in charge, you or the client (assuming the client is mentally competent)? (required)  
     
8 Do you have the ability to cheerfully follow instructions? (required)  
     
9 Do you need to constantly talk about yourself and your personal problems, rather than to keeping the conversation turned to your client and their needs? (required)  
     
10 Do you have the ability to see the needs of others and really care for them? (required)  
     

Section 12 - References - 5 required EXCLUDING family members

Number Question Effective Date Expiration Date
1 Name / relationship: (required)  
     
2 Phone: (required)  
  (Numeric Answer Only)    
3 Name / relationship: (required)  
     
4 Phone: (required)  
  (Numeric Answer Only)    
5 Name / relationship: (required)  
     
6 Phone: (required)  
  (Numeric Answer Only)    
7 Name / relationship: (required)  
     
8 Phone: (required)  
  (Numeric Answer Only)    
9 Name / relationship: (required)  
     
10 Phone: (required)  
  (Numeric Answer Only)    



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.