Background

Honor HealthCare Group
4813 Jonestown Road, Suite 201
Harrisburg, PA 17109

Phone: (717) 715-8700
Fax: (717) 715-8704

Angels On Call
32 Red Hill Court
Newport, PA 17074

Phone: (717) 567-7937
Fax: (717) 567-7956

Angels on Call
1205 South 28th Street
Harrisburg, PA 17111

Phone: (717) 715-8700
Fax: (717) 715-8704

Angels on Call
717 Market Street, Suite 103
Lemoyne, PA 17043

Phone: (717) 963-8077
Fax: (717) 317-9126

Legacy Hospice & Palliative Care
4813 Jonestown Road, Suite 201
Harrisburg, PA 17109

Phone: (717) 715-8700
Fax: (717) 715-8704

Home Remedy Skilled Nursing
4813 Jonestown Road, Suite 201
Harrisburg, PA 17109

Phone: (717) 715-8700
Fax: (717) 715-8704

House Calls Rx
4813 Jonestown Road, Suite 201
Harrisburg, PA 17109

Phone: 1-877-MD4YOU1
Fax: (717) 715-8704

Personal Information


Name and Address










Position Details






Age and Citizenship


Yes
No

Yes
No

Yes
No

Driver's License and Vehicle

Yes
No


Yes
No

Yes
No

Education


High School


Yes
No






G.E.D.


Yes
No


Technical / Trade School


Yes
No




College

Yes
No










Skills / Certifications






Work Availability



Full-time
Part-time

Yes
No

Yes
No
Yes
No

Yes
No

Employment History


Employer 1 - (list most recent first)













Employer 2













Employer 3













Professional References


Reference 1






Reference 2






Reference 3






Criminal Background


Yes
No

I certify that any and all information submitted in this application form, resume or other information which I provide; and any statements which I make during any interview are true and accurate to the best of my knowledge. Nor will I withhold any information that would affect my application for employment. I understand that there is no obligation to consider or reconsider this application at any time, and that acceptance of this application does not constitute an offer of employment.



I authorize that inquiries may be made with my previous educators, employers, references, consumer credit, private or government agencies and any other individuals who may have knowledge of me or my work experience. I give my consent for any such person or agency to give assessment of my job performance, ability, fitness and/or other information that they may have, personal or otherwise. I agree to cooperate with such an investigation and release all parties from any and all liability, claims or damages, directly or indirectly, resulting from furnishing such information. Upon my written resonable and timely request, a description of the general scope and nature of any such inquiry will be provided to me.



By placing your name in the following box, you acknowledge that you have read and understand everything contained in this document and that all provided answers are true and accurate. *