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

Section 2 - General Information

Section 3 - Employment Verification

Section 4 - Education

Section 5 - Other Training: Certifications/Licenses

Section 6 - Current/Most Recent Employment

(Numeric Answer Only)
(Numeric Answer Only)

Section 7 - Previous Employment History 1

(Numeric Answer Only)
(Numeric Answer Only)

Section 8 - Previous Employment History 2

(Numeric Answer Only)
(Numeric Answer Only)
(Numeric Answer Only)

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

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

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

Section 13 - Resume - Summary of Skills (optional)

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.