Application Form

At Synergy HomeCare, we value the members of our CARE team.  

Office Location

Personal Information

Section 1 - General Information

Section 2 - Employment

Section 3 - Employment History

Section 4 - Reference

PLEASE INDICATE THE TIMES YOU WILL BE ABLE TO WORK (this will be completed during in-person interview process):

 

Time

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

AM   5:00 - 6:00

 

 

 

 

 

 

 

6:00 - 7:00

 

 

 

 

 

 

 

7:00 - 8:00

 

 

 

 

 

 

 

8:00 - 9:00

 

 

 

 

 

 

 

9:00-10:00

 

 

 

 

 

 

 

10:00-11:00

 

 

 

 

 

 

 

11:00-12:00

 

 

 

 

 

 

 

PM   12:00- 1:00

 

 

 

 

 

 

 

1:00 – 2:00

 

 

 

 

 

 

 

2:00 - 3:00

 

 

 

 

 

 

 

3:00 – 4:00

 

 

 

 

 

 

 

4:00 – 5:00

 

 

 

 

 

 

 

5:00 - 6:00

 

 

 

 

 

 

 

6:00 - 7:00

 

 

 

 

 

 

 

7:00 - 8:00

 

 

 

 

 

 

 

8:00 - 9:00

 

 

 

 

 

 

 

9:00-10:00

 

 

 

 

 

 

 

10:00-11:00

 

 

 

 

 

 

 

11:00-12:00

 

 

 

 

 

 

 

AM  12:00- 1:00

 

 

 

 

 

 

 


TERMS & CONDITIONS / NON-COMPETE AGREEMENT FOR CAREGIVERS

 

 

This agreement is between Synergy HomeCare and  _______________________________________ (print your name) in which Synergy HomeCare and applicant agree to the following:

 

  1. I understand that no fees will be collected from me (the applicant) by Synergy HomeCare.
  2. While I am a caregiver on assignment, I am an employee of Synergy HomeCare and I am not authorized to:
  • Operate the client’s machinery, except standard office equipment.
    • Render an opinion on behalf of Synergy HomeCare on the client’s financial statements, or sign my name to any fax returns.
    • Handle cash, negotiables or other valuables without written permission from Synergy HomeCare or may not, under any circumstances, transport or convey monies, securities or any negotiable instruments (including, but not limited to, delivering bank deposits to bank or other institution.)
  1. I understand that registering with Synergy HomeCare is not a guarantee of employment.
  2. I will notify Synergy HomeCare of any event that may prevent me from accepting or completing an assignment.  If I am unable to complete my assignment, I will give Synergy HomeCare a minimum of one (1) week notice.  I understand that if I do not report to an assignment and I do not contact Synergy HomeCare prior to the assignment start time, Synergy HomeCare may assume that I have voluntarily quit and I will no longer be eligible to work through or be represented by Synergy HomeCare.
  3. Synergy HomeCare may provide me with opportunities and or job interviews in my field of caregiving.  Synergy HomeCare shall, at its own expense, spend time and effort researching the job market and contacting potential clients, which efforts may result in resume presentation and or job interviews.  In consideration for the services provided above, I agree that I will not directly solicit or seek employment from any individual or any contact associated with or referred by same, with whom Synergy HomeCare presents my resume to and/or arranges an interview with, and/or places me on assignment with, now or at any time during the twelve (12) months following my resume presentation, interview or assignment.  I understand if I do solicit and accept employment with any potential employers in which Synergy HomeCare has presented my resume to within twelve (12) months and do accept employment as either a permanent, contract or temporary position, an employment fee will be collected from me.

 

Our employees are often placed in positions where they are required to handle information or work with procedures that are proprietary to our clients.

 

  1. I understand the information I come in contact with is confidential and proprietary.
  2. I will not at any time during my employment or any time thereafter publish, disclose, or utilize any confidential or proprietary information and material gained while working as an employee with any client.
  3. I will protect the integrity of written records by storing and working with them in an appropriate manner, I will not copy any documents or portion of any document without specific instructions to do so.
  4. I understand that as an employee of Synergy HomeCare I may be sent on future assignments to clients that may have been previously serviced directly or indirectly by competitors of Synergy HomeCare.  I will not disclose details of my work with any client.

 

I have read the Terms and Conditions/Non-Compete Agreement and I understand that they are applicable when I am employed by or represented by Synergy HomeCare.  I also certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on the application shall be grounds for dismissal.  I authorize investigation of all statements contained herein and the references listed herein to give you any information concerning my previous employment and any pertinent information they may have, and release all parties from liability for any damage that may result from furnishing same to you.

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.  If employed by Synergy HomeCare, I will comply with all rules and regulations of the company.  I agree to submit to a physical and or drug examination if required.  I also authorize my former employers to give any information they have regarding me to Synergy HomeCare, whether or not it is on their records.  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 (DVM). I hereby release Synergy HomeCare from all liability for and damage whatsoever for issuing the same.  I understand that if any fraudulent information is given on this application, it will be grounds for immediate termination from my position.  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 origin, sexual preference, handicap, or age.