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CONTACT INFORMATION
What office location would you like your application sent to*:
First Name*
Last Name*
Address 1*
Address 2
City*
State*
Zip*
Country*
Home Phone*
Cell Phone
E-mail*
Verify E-mail*
Position Applying For*:
What shifts do you prefer?* 7am to 3pm
3pm to 11pm
11pm to 7am
7am to 7pm
7pm to 7am
What days of the week are you available?*
Monday
Wednesday
Friday
Sunday
Schedule Will Vary
Tuesday
Thursday
Saturday
Every Other Weekend
Every Weekend
Do you have nursing experience with any of the following (check off applicable items):*
AVI Vest
C-Pap
G-Tube
J-Tube
Nebulizer Treatments
Tracheostomy Care
Wound Vac
TPN
Cough Assist
School Nurse Certification
Hoyer Lift
Bi-Pap
IV Certification
Hospice
NG Tube
Wound Care
Pediatric Nursing (under 18 y/o)
Newborn Nursing (under 36 mo.)
Ventilator Support (LTV 950)
Ventilator Support (LTV 1150)
Central Lines
J/G Tube
For Pennsylvania Applicants Only
Federal (FBI) Criminal Background Check
PA Department of Public Welfare (DPW) Childline Clearance
PA State Police Clearance
Enter Date:  
Enter Date:  
Enter Date:  
Are you legally eligible for employment
in the United States?*
Date available to begin work?*
Name and Telephone number of person to be notified in case of emergency:*


EDUCATION
High School
City
State
Zip Code
Business/Trade/Technical
City
State
Zip Code
College
City
State
Zip Code
Graduate
City
State
Zip Code


PREVIOUS EMPLOYMENT
Company Name
Company Address
Company Address 2
City
State
Zip Code
Name of Supervisor
Supervisor Phone Number
Describe Your Work:
Company Name
Company Address
Company Address 2
City
State
Zip Code
Name of Supervisor
Supervisor Phone Number
Describe Your Work:
Company Name
Company Address
Company Addres 2
City
State
Zip Code
Name of Supervisor
Supervisor Phone Number
Describe Your Work:


REFERENCE
Colleague Name
Colleague Phone
Colleague Position
Address 1
City
State


ADDITIONAL INFORMATION
Where did you hear about us? *
Internet Search Engine – Google
Internet Search Engine – Yahoo
Internet Search Engine – Bing
Internet Search Engine – Other
Internet Website - which?

Friend
Radio
Billboard
Employment Flyer
Yellow Pages
Newspaper - which?

Magazine - which?

Other - which?

Comments:
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In compliance with federal and state law, we are an Equal Opportunity Employers that manages per diem employment and employee relations practices without regard to race, age, color, religion, national origin, medical condition, marital status, sex, citizenship status, ancestry, sexual orientation, creed, disability, or handicap (as required by law). Our agency shall adhere to applicable state directed mandates. I understand that PHHC is a per diem employer.

For more information about career opportunities or training programs in your area,
please do not hesitate to call us at 1-800-603-CARE (2273).