Date: 8/20/2014

Application Form

Synergy HomeCare North West N.J.

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 2 - General Information

Number Question Effective Date Expiration Date
1. Best time/day and number to reach you? (required)  
     
2. Date Available? (required)  
     
3. Job Type? (required)  
 
 
 
 
 
4. How did you learn about Synergy HomeCare? (required)  
     
5. Have you ever applied at Synergy HomeCare? If Yes, where? (required)  
 
6. Have you ever worked for Synergy HomeCare before? (required)  
     
7. Has your professional license or certification ever been investigated or suspended? If Yes, please explain (required)  
 
8. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
8a If you answered yes to #8 please explain:  
     
9. Have you ever been named as a defendant in a professional liability action? (required)  
     
10. Have you ever been released from a job due to discipline or being fired? (required)  
     
11. Would you consent to a drug test at the client's request? (required)  
     
12. Are you covered by auto liability insurance? (required)  
     

Section 3 - 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 4 - Education

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

Section 5 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1. Do you have a New Jersey State CHHA license? (required)  
     
2. Do you have a New Jersey State CNA license? (required)  
     
3. Do you have any other New Jersey State health care licenses (RN etc.)?  
     
4. If Yes, please specify:  
     
5. CPR Certified? (required)  
     
6. First Aid Certified? (required)  
     
7. Have you had a recent TB test? (required)  
     
8. What were the results?  
 
 

Section 6 - Current/Most Recent Employment

Number Question Effective Date Expiration Date
1. Current Employer: (required)  
     
2. Address: (required)  
     
3. City: (required)  
     
4. State: (required)  
     
5. Zip Code: (required)  
     
6. Start Date: (required)  
     
7. End Date (if you still work there skip question):  
     
8. Hours Worked: (required)  
 
 
 
9. Position/Title: (required)  
     
10. Describe Your Responsibilities: (required)  
 
11. Supervisor's Name/Title: (required)  
     
11. Supervisor's Phone: (required)  
     
13. Reason for Leaving: (required)  
 
14. Starting Salary: (required)  
  (Numeric Answer Only)    
15. Ending Salary: (required)  
  (Numeric Answer Only)    
16. May we contact? (required)  
     

Section 7 - Previous Employment History 1

Number Question Effective Date Expiration Date
1. Employer/Company Name: (required)  
     
2. Address:  
     
3. City: (required)  
     
4. State: (required)  
     
5. Zip Code:  
     
6. Start Date: (required)  
     
7. End Date: (required)  
     
8. Hours Worked: (required)  
 
 
 
9. Position/Title: (required)  
     
10. Describe Your Responsibilities: (required)  
 
11. Supervisor's Name/Title: (required)  
     
12. Phone: (required)  
     
13. Reason for Leaving: (required)  
 
14. Starting Pay: (required)  
  (Numeric Answer Only)    
15. Ending Pay: (required)  
  (Numeric Answer Only)    
16. May we contact? (required)  
     

Section 8 - Previous Employment History 2

Number Question Effective Date Expiration Date
1 Employer/Company Name:  
     
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:  
  (Numeric Answer Only)    
13 Reason for Leaving:  
     
14 Starting Salary:  
  (Numeric Answer Only)    
15 Ending Salary:  
  (Numeric Answer Only)    
16 May We Contact?  
     

Section 9 - Work References 1 (no family & friends)

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

Section 10 - Work References 2 (no family & friends)

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

Section 11 - Work/other References 3 (no family & friends)

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

Section 13 - Resume - Summary of Skills (optional)

Number Question Effective Date Expiration Date
1. Copy/Paste Resume or Summary of Skills  
 



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. 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.