Synergy HomeCare of Arlington/Alexa 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
*
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Section 1 -
General Information (PG 1)
Do you have a current Virginia CNA License?
(required)
Yes
No
If so, what is your license number?
(Numeric Answer Only)
Do you have your Virginia CNA Certificate?
Yes
No
Do you have a Virginia HHA or PCA Certificate?
(required)
Yes
No
Have you ever applied at Synergy HomeCare in the past?
(required)
Yes
No
Has your professional license or certification ever been investigated or suspended?
(required)
Yes
No
Have you ever been named as a defendant in a professional liability action?
(required)
Yes
No
Have you ever been released from a job due to discipline or being fired?
(required)
Yes
No
Would you consent to a drug test at the client's request?
(required)
Yes
No
Some of our clients aren’t located near a bus stop or metro station. Do you have a car to get to and from work?
(required)
Yes
No
Do you have current auto liability insurance?
(required)
Yes
No
Any objections to travel if required by the position?
(required)
Yes
No
Can you submit verification of your legal right to work to in the U.S?
(required)
Yes
No
If 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:
How did you hear about Synergy HomeCare?
(required)
Do you live in the State of Virginia?
(required)
Yes
No
Do you have a current copy of your TB Results or Chest X-ray?
(required)
Yes
No
Can you provide proof of your Covid vaccine and/or booster? (Required)
(required)
Yes
No
Most of our open cases are weekend care. Are you able to work on Saturday and Sunday?
(required)
Yes
No
Can you commute to the following Areas in Virginia: Tyson, Mclean, Burke, Fairfax, or Vienna?
(required)
Yes
No
Have you been hired under any other name?
Yes
No
Section 2 -
References
Person to notify in case of emergency: (name, relationship, street address, city, state, zip, phone)
(required)
Please list a professional reference from either business, school , or anyone relevant excluding family members: (name, relationship, phone)
(required)
Please list a professional reference from either business, school , or anyone relevant excluding family members: (name, relationship, phone)
(required)
Section 3 -
Education
High school (list name, location, graduation month and year along with diploma or degree received)
College (list name, location, graduation month and year along with diploma or degree received)
Graduate School (list name, location, graduation month and year along with diploma or degree received)
Section 4 -
Employment History 1
Name of Employer:
(required)
Job Title:
(required)
Dates Employed:
(required)
Address:
(required)
Reason for leaving if not currently employed:
(required)
Supervisor's Name, Title, and Phone Number:
(required)
May we contact this employer?
(required)
Yes
No
Section 5 -
Employment History 2
Name of Employer:
(required)
Job Title:
(required)
Dates Employed:
(required)
Address:
(required)
Reason for leaving if not currently employed:
(required)
Supervisor's Name, Title, and Phone Number:
May we contact this employer?
(required)
Yes
No
Section 6 -
Employment History 3
Name of Employer:
Job Title:
Dates Employed:
Address:
Reason for leaving if not currently employed:
Supervisor's Name, Title, and Phone Number:
May we contact this employer?
Yes
No
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