SYNERGY HomeCare of Mesa East 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.
Personal Information
First Name
*
Last Name
*
Social Security Number
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
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*
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Section 1 -
General Information
Have you ever worked for Synergy HomeCare?
(required)
Yes
No
Would you consent to a drug test at a clients request?
(required)
Yes
No
Do you have relaible means of transportation?
(required)
Yes
No
Can you provide documentation of a driver's license and auto insurance?
(required)
Yes
No
Have you ever used any other names which is necessary for us to know in order for us to verify your employment or educational records?
(required)
Yes
No
Can you submit verification of your legal right to work in the U.S.?
(required)
Yes
No
If you will be employed on a Visa, please specify type of work visa:
Please list any reason why you might be unable to perform consistently and promptly any of the job duties:
(required)
Show Plain Text
How did you learn about Synergy HomeCare?
(required)
-- Select an Option --
Synergy Homecare Employee
Caring.Com
Indeed
Zip Recruiter
Other
Section 2 -
Other:
Are you at least 18 years old?
(required)
Yes
No
Are you a smoker?
(required)
Yes
No
I certify that all information provided herein 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 the information listed above: By typing in your name we are accepting your signature
(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