Date: 12/1/2015

Application Form

Synergy HomeCare of South Denver

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 *
Home Phone * Zip *
Work Phone Driver's License Number
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1. How did you learn about this position? (required)  
2. Have you ever worked for SYNERGY HomeCare? (required)  
3. Would you consent to a drug test? (required)  
4. Do you have a reliable means of transportation? (required)  
5. Do you have caregiving experience? (required)  
6. Desired rate of pay for this position (required)  

Section 2 - Education

Number Question Effective Date Expiration Date
1. Highest Level of Education Completed? (required)  
2. Do you have your CNA License? (required)  

Section 3 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you a US Citizen? (required)  
2. Are you authorized to work in the U.S.? (required)  

Section 4 - Certification

Number Question Effective Date Expiration Date
1. 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)  
2. I authorize my former employers to give any information they have regarding me to SYNERGY HomeCare, whether or not it is on their records. (required)  
3. 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)  
4. 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)  
5. 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)  

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.