Synergy HomeCare of Austin 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 *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Are you available if a job becomes available last minute? (required)

Yes No

Date Available? (required)

Job Type? (required)

Can you provide documentation of a driver's license and auto insurance? (required)

Yes No

Geographic Preference/Willingness to travel (required)

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Any Travel Limitations? (required)

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Willings to service clients with pets? (required)

Yes No

Willingness to provide services to client that smokes? (required)

Yes No

Willingness to provide transportation or run errands in your vehicle? (required)

Yes No

Willingness to provide transportation or run errands in the clients vehicle? (required)

Yes No

What are your personal strengths? (required)

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Why do you want to work in homecare? (required)

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In the past what kind of circumstances kept you from showing up to an assigned shift? (required)

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Tell me about a client you were able to engage with and improve their quality of life? (required)

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Section 2 - Employment Verification

Are you eligible to work in the United States? (required)

Yes No

Section 3 - Education

Name of High School: (required)

Did you graduate? (required)

Yes No

Additional Education (vocational, undergraduate, etc.) (required)

Yes No

If yes, please list the name of the school and years attended (From/To) (required)

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Section 4 - Employment History

Are you currently employed? (required)

Yes No

Current Employer/Most Recent Employer (required)

Address: (required)

Start Date: (required)

End Date: (required)

Position/Title: (required)

Describe Your Responsibilities: (required)

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Supervisor's Name/Title: (required)

Supervisor's Phone/Email/Fax: (required)

Reason for Leaving: (required)

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Section 5 - Employment History (Previous Job)

Previous Employer: (required)

Address: (required)

Start Date: (required)

End Date: (required)

Hours Worked: (required)

Position/Title: (required)

Describe Your Responsibilities: (required)

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Supervisor's Name/Title: (required)

Supervisor's Phone/Email/Fax: (required)

Reason for Leaving: (required)

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Section 6 - Employment History (continued)

Previous Employer: (required)

Address: (required)

Start Date: (required)

End Date: (required)

Hours Worked: (required)

Position/Title: (required)

Describe your Responsibilities: (required)

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Supervisor's Name/Title: (required)

Supervisor's Phone/Email/Fax: (required)

Reason for Leaving: (required)

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Section 7 - Reference 1

Name: (required)

Company/Relationship: (required)

Phone: (required)

Section 8 - Reference 2

Name:

Company/Relationship: (required)

Phone: (required)

Section 9 - Other Training: Certifications/Licenses

CPR (required)

First Aid (required)

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Section 10 - Vaccines

TB (required)

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Hepatitis B (required)

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Section 11 - Emergency Contact Information

Name (required)

Address:

Phone number: (required)

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. Thank you for your interest in the Caregiving position and the opportunity in joining our SYNERGY HomeCare team. The next step after this application has been completed is to submit the applicant profile along with a copy of two forms of identification. If you have any questions or would like to set a time to come in please call the office 512-872-6116. 24 hr On call phone - 512-897-0373

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