Synergy HomeCare of Rochester 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.
Personal Information
First Name
*
Last Name
*
Home Phone
*
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Mobile Phone
Email
*
Address 1
*
Address 2
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*
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*
Driver's License Number
--
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Section 1 -
General Information
Covid Vaccination Status
Yes
No
Date Available?
Job Type?
-- Select an Option --
Part Time
On Call
Any
Has your professional license or certification ever been investigated or suspended?
(required)
Yes
No
Can you provide documentation of a driver's license and auto insurance?
(required)
Yes
No
Have you ever been released from a job due to discipline or being fired?
(required)
Yes
No
Are you applying for a specific job ad? If yes, please list the city/location.
(required)
Are you experienced with providing care to Alzheimer's/Dementia patients?
(required)
Yes
No
Are you experienced with administering range of motion excercises to a patient?
(required)
Yes
No
Are you experienced with bathing assistance?
(required)
Yes
No
Are you experienced with emptying a catheter bag?
(required)
Yes
No
Are you experienced with gait belt assistance?
(required)
Yes
No
Are you experienced with incontinence care?
(required)
Yes
No
Are you experienced with a hoyer lift?
(required)
Yes
No
Are you experienced with walking assistance?
(required)
Yes
No
Are you experienced with transfers?
(required)
Yes
No
Are you experienced with dressing assitance?
(required)
Yes
No
Are you experienced in checking vital signs?
(required)
Yes
No
Are you experienced with hospice patients?
(required)
Yes
No
Would you consent to a drug test at the client's request?
(required)
Yes
No
Are you allergic to animals?
(required)
Yes
No
Please explain what type of animals (ex: large dogs) you cannot work with?
(required)
Section 2 -
Employment Verification
Are you authorized to work in the U.S.?
(required)
Yes
No
If you are not a U.S. citizen, please indicate VISA type and number.
Section 3 -
Education
Name and Location of High School:
Did you graduate?
Yes
No
Years Attended:
Additional Education:
Show Plain Text
Section 4 -
Other Training: Certifications/Licenses
Do you have a current CPR certification?
(required)
Yes
No
Do you have a current First Aid certification?
(required)
Yes
No
Do you have a current negative TB test?
(required)
Yes
No
Are you a CNA? Provide license #
Section 5 -
Current Employment
Current Employer:
Address (include City, State, and Zip Code):
Position/Title:
Describe Your Responsibilities:
Show Plain Text
Start Date:
End Date:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Starting Wage:
Ending Wage:
Section 6 -
Employment History
Last Employer:
Address (include City, State, and Zip Code):
Position/Title:
Describe Your Responsibilities:
Show Plain Text
Start Date:
End Date:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Starting Wage:
Ending Wage:
Section 7 -
Employment History
Last Employer:
Address (include City, State, and Zip Code):
Position/Title:
Describe Your Responsibilities:
Start Date:
End Date:
Supervisor's Name/Title:
Supervisor's Phone:
Reason For Leaving:
May we contact?
Yes
No
Starting Wage:
Ending Wage:
Section 8 -
Availability
Mornings from 6:00AM to NOON
(required)
Yes
No
Afternoons from NOON to 5:00 PM
(required)
Yes
No
Evenings from 5:00 PM to 10:00 PM
(required)
Yes
No
Overnight from 10:00 PM to 6:00 AM
(required)
Yes
No
What days are you available to work including the hours?
(required)
Show Plain Text
Section 9 -
Professional Reference 1
Name:
(required)
Their Employer:
(required)
Phone Number:
(required)
Relationship to you:
(required)
Section 10 -
Professional Reference 2
Name:
Their Employer:
Phone Number:
Relationship to you:
Section 11 -
Professional Reference 3
Name:
Their Employer:
Phone Number:
Relationship to you:
Section 12 -
Emergency Contact Information
First and Last Name:
(required)
Phone 1:
(required)
Phone 2:
Relationship:
(required)
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