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Contact Information


General Employment Information

Have you ever applied for employment with us?(Required)
Are you able to work full time?(Required)
(Do not include religious holidays)
Are you able to work over time if asked?(Required)
Are You eligible for work in the U.S.?(Required)
Are You 18 years Of Age Or Older?(Required)
Do you posses a valid drivers license?(Required)
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Employer History - Most Recent

Begin With Your Most Recent Employment (1) And Continue With Past Employment
May We Contact Employer?

Employer History - Past Employment 1 of 2

May We Contact Employer?

Employer History - Past Employment 2 of 2

May We Contact Employer?


Education History - List High School and any post High School education. Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools
Click the + button on the far right to add additional high schools, colleges, universities, technical colleges, or trade schools
Full Name of School
Major Subject
Highest Grade Or Year Completed
Degree Earned

Military or Other Special Training/Skills


Add 2 References(Required)
Click the + button on the right to add additional references
Occupation Business Phone Number
Telephone Number


Applicant Statement

I certify that all answers given by me are true, accurate and complete, I understand that the falsification, misrepresentation or omission of fact on this application (or any other accompanying or required documents) will be cause for denial of employment or immediate termination of employment, regardless of when or how discovered.

Questions regarding this statement should be directed to any employment interviewer before signing. The application will be given every consideration, but its receipt does not imply that the applicant will be employed.

It is the policy of the company to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, sex, national origin, marital status, expunged juvenile records, or pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability, any and other characteristic protected by Federal, State or Local law.

I authorize the investigation of all statements and information contained in this application. I release from all liability anyone supplying such information and I also release the employer from all liability that might result from making an investigation.

If hired, I agree to abide by company rules and regulation, and understand that, if employed, my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either Madelia Health or me, I further understand that no representation, whether oral or written by any representative or agent of Madelia Health, at any time, can constitute a contract of employment. I understand that Madelia Health and its Board of Directors shall have the maximum discretion permitted by law to administer, interpret, modify, discontinue, enhance or otherwise change all policies, procedures, benefits or other terms or conditions of employment. No representative or agent of Madelia Health has the authority to enter into any agreement for employment for any specified period of time or to make any change in any policy, procedure, benefit or other term or condition of employment other than in a document signed by the Chief Executive Officer, or to make any agreement contrary to the foregoing.

I hereby understand Madelia Health is a drug free workplace and all new employees are subject to a Drug/alcohol screening upon hire. It is mandatory all employees have an annual flu vaccination or be exempted in accordance with Madelia Health’s policy.

I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied on this application by me.
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