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.

Office Location

Personal Information

Section 1 - Education

Section 2 - Credentials

Section 3 - Work History

Section 4 - Employment History - (Or submit Resume separately)

(Numeric Answer Only)

Section 5 - Previous Employment (Skip with Resume submission)

(Numeric Answer Only)

Section 6 - Previous Employment (Skip with Resume submission)

(Numeric Answer Only)

Section 7 - Previous Employment - 4

Section 8 - Other

In submitting this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete.  I also understand that the omission, concealment, or misrepresentation of any fact in this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment.

I give permission to Synergy HomeCare to use any information in this application to enable it and its agents to verify the information contained in this application.  I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Synergy HomeCare with regard to any of the subjects covered by this application.  I also understand that in connection with my application for employment or my employment, Synergy HomeCare may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation .   I release Synergy HomeCare, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information.

In consideration of my employment and of my being considered for employment by Synergy HomeCare I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice.  I also understand that if employed, I will be an employee at will and employed for no definite period of time.  I understand that either Synergy HomeCare or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Synergy HomeCare, at any time, can constitute a contract of employment.  No representative or agent of Synergy HomeCare has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing.

I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws.  If I receive an offer of employment I agree that my continued employment may be contingent on the results.

My signature below certifies that I agree to be bound by the terms and conditions stated in this application, which contains all the understandings between SYNERGY HomeCare and me concerning the topics addressed herein, and supersedes any prior inconsistent understandings between SYNERGY HomeCare and me on such issues.  By submitting this application for employment and SYNERGY HomeCare’s review of it, you and SYNERGY HomeCare mutually contract and agree that any and all claims and/or disputes, past, present or future, between you and SYNERGY HomeCare, arising out of or related to your application for employment shall be decided by final and binding arbitration and not by way of court or jury trial. Expect as provided in this Arbitration Agreement, arbitration shall be in accordance with the then current Employment Arbitration Rules of the American Arbitration Association (“AAA Rules”), available via the internet at www.adr.org.  The Federal Arbitration Act (9 U.S.C. § 1 et seq.) shall apply to this Arbitration Agreement.  If for any reason the AAA will not administer the arbitration, either party may apply to a court of competent jurisdiction with authority over the location where the arbitration will be conducted for appointment of a neutral arbitrator. Covered claims include those relating to the employment application or hiring process (including, without limitation, claims under the Defend Trade Secrets Act, Fair Credit Reporting Act, Civil Rights Act of 1964, Age Discrimination and Employment Act, and Americans with Disabilities Act, and state common law or statutory equivalents). There will be no right or authority for any claim and/or dispute covered under this Arbitration Agreement to be brought, heard, or arbitrated as a class or collective action, nor shall the Arbitrator have any authority to hear or arbitrate any such class or collective action.  Regardless of anything else in this Arbitration Agreement and/or the AAA Rules, disputes regarding the enforceability or validity of this Class Action Waiver may be determined only by a court and not by an arbitrator.  Nothing in this Arbitration Agreement prevents you from filing claims or charges before the Equal Employment Opportunity Commission, U.S. Department of Labor, National Labor Relations Board, or Office of Federal Contract Compliance Programs and law enforcement authorities. An electronic signature is the electronic equivalent of a hand-written signature.