Synergy HomeCare of Chicago 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. eRSP’s online application is not currently fully-compatible with mobile device web browsers. Please submit your application via a desktop or laptop web browser.

Personal Information

First Name *

Last Name *

Social Security Number *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Date Available? (required)

Job Type? (required)

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

Yes No

Do you have a reliable vehicle? (required)

Yes No

Auto Insurance Expiration Date:

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)

Yes No

If yes, please explain.

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Do you have childcare experience? (required)

Yes No

Have you had a Hep B Vaccine? (required)

Yes No

Where did you find us? (required)

Athletic and willing to participate in rigorous activities with client?

Yes No

Section 2 - Employment Verification

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

Section 3 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Years Attended (From/To): (required)

Additional Education (vocational, undergraduate, etc.)

Yes No

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

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Section 4 - Other Training: Certifications/Licenses

TB Tested

Yes No

Effective Date

Expiration Date

CPR Certified

Yes No

Effective Date

Expiration Date

HHA

Yes No

Effective Date

Expiration Date

CNA

Yes No

Effective Date

Expiration Date

Additional Certifications/Licenses:

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Section 5 - Current Employment

Current Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

Yes No

Section 6 - Employment History-2

Employer: (required)

Address:

City: (required)

State: (required)

Zip Code:

(Numeric Answer Only)

Start Date:

End Date:

Position, Responsibilities:

Supervisor:

Supervisor's Phone:

(Numeric Answer Only)

Reason For Leaving:

May we contact?

Yes No

Section 7 - Employment History-3

Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

Show Plain Text

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

Show Plain Text

May we contact?

Yes No

Section 8 - Reference 1

Name: (required)

Company: (required)

Phone: (required)

Section 9 - Reference 2

Name: (required)

Company:

Phone: (required)

Section 10 - Reference 3

Name: (required)

Company:

Phone: (required)

(Numeric Answer Only)

Section 11 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

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.

Signature