Application Form

Office Location

Select Office Location

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Section 1 - General Information

How did you learn about this position? (required)

Have you ever worked for SYNERGY HomeCare? (required)

Yes No

Would you consent to a drug test? (required)

Yes No

Do you have a reliable means of transportation? (required)

Yes No

Do you have caregiving experience? (required)

Desired rate of pay for this position (required)

What is your COVID-19 Status? (required)

Section 2 - Education

Highest Level of Education Completed? (required)

Do you have your CNA License? (required)

Yes No

Section 3 - Employment Verification

Are you authorized to work in the U.S.? (required)

Previous Work Experience #1 (name)

Previous Work Experience #1 (phone)

Previous Work Experience #1 (title)

Previous Work Experience #2 (name)

Previous Work Experience #2 (phone)

Previous Work Experience #2 (title)

Section 4 - Certification:

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. (required)

Yes No

I authorize my former employers to give any information they have regarding me to SYNERGY HomeCare, whether or not it is on their records.

Yes No

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 (DMV). (required)

Yes No

I understand that if any fraudulent information is given on this application, it will be grounds for immediate termination from my position if I am hired by SYNERGY HomeCare. (required)

Yes No

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 orgin, sexual preference, handicap, or age. (required)

Yes No

I certify that information contained in this application is true and complete. I authorize the verification of any or all information listed above.

Signature

SYNERGY HomeCare of Denver Application Form

Office Location

Personal Information

Section 1 - General Information

Section 2 - Education

Section 3 - Employment Verification

Section 4 - Certification: