Date: 6/19/2013

Application Form

Synergy HomeCare of the Mainline

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.

 

To work with Synergy HomeCare you must have the following:

  • You MUST have your OWN Vehicle - Borrowing a car and getting dropped off at assignments is NOT ACCEPTABLE! 
  • First Aid Certification
  • CPR Certification
  • Any Licenses/Certifications (CNA, HHA, RN, etc)
  • Auto Insurance (with you listed as an insured person)
  • Evidence of a 2 Step TB Test
  • Any previously run background checks (example: ChildLine, State Police, etc)
    • Please note that the State of Pennsylvania now requires that all homecare applicants go through a battery of background checks. Please understand that once completed, these can be used for application at any homecare agency in the state.  

 

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
** Please Choose the Type of Position (required)  
 
 
 
1. Job Type? (required)  
 
 
 
 
2. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
3. If yes, please explain (If, no write (required)  
 
4. How did you hear about Synergy HomeCare? (required)  
 
 
 
 
 
5. Have you ever worked for Synergy HomeCare before? (required)  
     
6. Has your professional license/certification ever been investigated or suspended? (required)  
     
7. Have you ever been convicted of a felony? (required)  
     
8. Have you ever been named as a defendant in a professional liability action? (required)  
     
9. Have you ever been released from a job due to discipline or being fired? (required)  
     
10. Would you consent to a drug test at the client's request? (required)  
     
11. Do you OWN a reliable vehicle? (required)  
     
12. Are you covered by auto liability insurance? (required)  
     
13. Willing to work with a client that has dementia? (required)  
     
14. Are you willing and able to Lift and Transfer a Client? (required)  
     
15. Are you willing to provide transportation to a client? (required)  
     
16. Are you willing to provide transportation or run errands in the client's vehicle? (required)  
     
17. Because we service clients in multiple counties (DE, Chester & the Main Line) and staff a variety of cases, employment is conditional upon a caregiver’s willingness to drive 25 miles for a 2 hour case. Are you willing to drive 25 miles for a 2 hour case? (required)  
     
18. If No, Please explain why. (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)  
 
 
 
 

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.) (required)  
     
6. If yes, please list the name of the school and years attended (From/To)  
 

Section 4 - Getting To Know You Better!
Number Question Effective Date Expiration Date
1. Are you a State Certified CNA or a recent Grad of a CNA School? (required)  
     
2. Are you an experienced caregiver with no State Certifications (required)  
     
3. Do you have a valid First Aid Certification? (required)  
     
4. Do you have valid CPR Certification? (required)  
     
5. Please write a short paragraph detailing how many years of experience you have in direct care and what motivates you to be a caregiver. (required)  
 

Section 5 - Most Recent Employment
Number Question Effective Date Expiration Date
1 Most Recent Employer: (required)  
     
2 Address: City State and Zip Code (required)  
     
3 Start Date: (required)  
     
4 End Date: (required)  
     
5 Position/Title:  
     
6 Describe Your Responsibilities:  
 
7 Supervisor's Name/Title: (required)  
     
8 Supervisor's Phone: (required)  
     
9 Reason for Leaving:  
 
10 May we contact? (required)  
     

Section 6 - Previous Employer
Number Question Effective Date Expiration Date
1 Employer: (required)  
     
2 Address: City State and Zip Code (required)  
     
3 Start Date:  
     
4 End Date:  
     
5 Position/Title:  
     
6 Describe Your Responsibilities:  
 
7 Supervisor's Name/Title: (required)  
     
8 Supervisor's Phone: (required)  
     
9 Reason for Leaving:  
 
10 May we contact? (required)  
     



By submitting this application electronically, I hereby certify that the answers given by me to all of the questions contained on this application form are true and correct 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 (DVM). 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 immediate termination from my position. 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.