Synergy HomeCare of Sun City Application Form
Application Form
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.
Office Location
Select Office Location
-- Select Office --
Phoenix AZ02
Sun City AZ02
Personal Information
First Name
*
Last Name
*
Home Phone
*
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*
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*
Address 2
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*
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Section 1 -
Personal Information
Date available for work?
(required)
How did you learn about SYNERGY HomeCare?
(required)
-- Select an Option --
SYNERGY Website or other online ad
Craigslist
Ziprecruiter.com
SYNERGY Employee or Sign on Bell Road
MyCNAJobs.com
Do you have a reliable vehicle to drive?
(required)
Yes
No
Can you submit verification of your legal right to work in the U.S.?
(required)
Yes
No
If you have another employer, will your work there prohibit you from giving us definite days/hours of availability?
(required)
Yes
No
Have you ever been named as a defendant in a professional liability action?
(required)
Yes
No
Have you ever been released from a job due to discipline or being fired?
(required)
Yes
No
Would you consent to a drug test if requested?
(required)
Yes
No
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)
Yes
No
Who should we contact in case of an emergency? (Name and Phone Number)
(required)
Show Plain Text
Section 2 -
Certifications: Will be required before hire
Is your CPR certification current? (On line courses not accepted)
(required)
Yes
No
Expiration Date
*
Is your First Aid certification current? (On line courses not accepted)
(required)
Yes
No
Expiration Date
*
Have you been tested for TB (tuberculosis) within the past year?
(required)
Yes
No
Expiration Date
*
Are you covered by auto liability insurance?
(required)
Yes
No
Expiration Date
*
Section 3 -
Licenses
Do you hold any state licenses/certifications? (CNA, certified caregiver, RN, MA, etc) Please list credential(s) and State(s)?
Has your professional license or certification ever been investigated or suspended? If yes, please explain
Section 5 -
Experience
How many years have you worked as a home care caregiver?
(required)
(Numeric Answer Only)
How many years of providing personal care (toileting, showers, etc.)?
(required)
(Numeric Answer Only)
How many years of providing hospice/end of life care?
(required)
(Numeric Answer Only)
Section 6 -
Skills: Have you performed these tasks?
Experience working with Alzheimer's/Dementia?
(required)
Yes
No
Comfortable working with Hoyer Lift and need NO further training?
(required)
Yes
No
Section 7 -
Transportation:
Willing/able to drive own car?
(required)
Yes
No
Willing/able to drive Client's Car?
(required)
Yes
No
Section 10 -
Employment History-Begin with most recent Employer
Are you currently employed? If so, where?
(required)
Yes
No
May we contact your current employer?
(required)
Yes
No
Facility/Employer:
(required)
Address (street/city/state/zip)
(required)
Dates employed from and to:
(required)
Supervisor's name and phone #
(required)
Summary of job duties:
(required)
Reason for leaving, if applicable:
Facility/Employer:
(required)
Address (Street,City,State,Zip Code):
(required)
Dates employed From and To:
(required)
Position held?
(required)
Supervisor's name and phone #
(required)
Summary of job duties:
(required)
Reason for leaving, if applicable:
Facility/Employer:
Address (Street,City,State,Zip Code):
Dates employed From and To:
Position held?
Supervisor's name and phone #
Summary of job duties:
Reason for leaving, if applicable:
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.
Signature
Submit Application
