Synergy HomeCare of North Valley 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.
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*
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*
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*
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*
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Section 1 -
General Information
Position Desired - Caregiver
(required)
Yes
No
Office Location North Valley
(required)
Yes
No
Do you have a current driver's liscense?
(required)
Yes
No
Do you have a reliable means of transportation?
(required)
Yes
No
Do you have the minimum amount of auto insurance as required by the state?
(required)
Yes
No
Section 2 -
Employment Verification
Are you authorized to work in the U.S.?
(required)
-- Select an Option --
I am authorized to work in the U.S. for any employer.
I am authorized to work in the U.S. only for my current employer.
I require sponsorship to work in the U.S.
I do not know my work status.
Section 3 -
Employment History
Most Recent Employer:
(required)
City:
State:
Start Date:
End Date:
Position/Title:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Section 4 -
Employment History
Previous Employer:
(required)
City:
State:
Start Date:
End Date:
Position/Title:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Section 5 -
Other Experience
How much experience do you have caregiving?
(required)
-- Select an Option --
None
6 Months or less
1 to 2 years
more than 2 years
How much experience do you have providing companionship for the elderly and disabled?
(required)
-- Select an Option --
None
6 months or less
1-2 years
More than 2 years
How much experience do you have providing housekeeping assistance?
(required)
-- Select an Option --
None
6 months or less
1-2 years
More than 2 years
How much experience do you have providing personal care to the elderly or disbaled?
(required)
-- Select an Option --
None
6 months or less
1-2 years
More than 2 years
What is your comfort level with providing personal care?
(required)
-- Select an Option --
Very comfortable
Mostly comfortable
Somewhat comfortable
Not comfortable at all
Section 6 -
Reference 1
Name:
(required)
Relationship:
(required)
Phone:
(required)
Section 7 -
Available Work Times
List days and times available
(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