Career Opportunities

Madonna Rehabilitation Hospital is an Equal Opportunity Employer.

Mission: Madonna Rehabilitation Hospital is a Catholic healthcare organization which exists to provide medical and rehabilitation services to children and adults with physical disabilities in Lincoln, Neb., and the surrounding region.

Core Values: Madonna Rehabilitation Hospital is dedicated to the healing ministry of Christ. In the spirit of our Catholic heritage and Benedictine traditions, we commit ourselves to the Core Values of:

• Collaboration


• Hospitality


• Respect


• Innovation


• Stewardship


• Teaching

The following information is requested in order to help us determine your qualifications for employment. We appreciate the time you spend in filling in this application form. Madonna Rehabilitation Hospital is a Catholic health care facility serving all faiths and, in accordance with state and federal laws, does not discriminate on the basis of age, race, color, religion, sex, physical or mental disability, natural origin, marital status, pregnancy, Vietnam era veteran status or receipt of public assistance. Madonna Rehabilitation Hospital is in compliance with Section 504, the Rehabilitation Act of 1973 and Americans with Disabilities Act of 1990.

Attach Resume:	Please attach Word or PDF document
PERSONAL INFORMATION
Date:	(This application will be kept on file for 30 days from the date of this application.)
Last Name:
First Name:
Middle Initial:
Home Address:
City, State, ZIP:
Home Phone:
Cell Phone:
Email Address:
Social Security Number:
Position(s) Applied For:
Desired Salary:
What date would you be available to begin employment:
I am applying for:	Full-Time Part-Time On-Call
Hours Per Week :
Shift Preferred:	Days Evenings Nights
Are you 16 years of age or older?:
	Yes No
Are you a U.S. citizen or otherwise legally entitled to work in the U.S.A.?:
	Yes No
Have you ever been employed by Madonna Rehabilitation Hospital?:
	Yes No
If yes, please specify dates and positions:
Do you have any family members who are employed by this organization?:
	Yes No
If yes, please specify:
Are you currently excluded, suspended or otherwise determined ineligible to participate in federally funded health care programs, including but not limited to Medicare and Medicaid?:
	Yes No
Have you ever been found guilty of abusing, neglecting or mistreating individuals?:
	Yes No
If yes, please explain:
Does your name appear on an abuse registry in this state or any other state?:
	Yes No
If yes, please explain:
Have you ever been convicted of a crime (i.e. misdemeanor or felony)?:
	Yes No
If your answer yes, please give details including dates, charges, and dispositions. Convictions are not an absolute bar to employment, but will only be considered in relation to specific job requirments:
Are you currently clinically licensed in NE?:
	Yes No
If no, are you eligible for licensure?:
	Yes No
Has your license and/or certification in any health care profession in this state or another state ever been revoked, suspended, limited, placed on probation or disciplined in any manner?:
	Yes No
If yes, please explain including state and date:
Professional Licenses and Certifications
Type of License/Certificate:
State:
ID Number:
Expiration Date (MM/DD/YYYY):
Type of License/Certificate:
State:
ID Number:
Expiration Date (MM/DD/YYYY):
Type of License/Certificate:
State:
ID Number:
Expiration Date (MM/DD/YYYY):
EDUCATION
How many full years of school completed?:
	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
If partial years have been completed, please indicate number of months:
	1 2 3 4 5 6 7 8 9 10 11
High School Name & Location:
Course of Study:
Degree/Certificate:	GED Diploma
Credit hours completed:	N/A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Technical School Name & Location:
Course of Study:
Degree/Certificate:	Associates Certification
Credit hours completed:	N/A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
College/University Name & Location:
Course of Study:
Degree/Certificate:	BA BS Associates
Credit hours completed:	N/A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Graduate/Other School Name & Location:
Course of Study:
Degree/Certificate:	Masters PhD
Credit hours completed:	N/A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
List the type of computer equipment and software you have experienced:
Describe any special skills or qualifications that may help you in the position for which you are applying:
How did you learn about this position?:
	Newspaper School Agency Madonna Web site Job Line Job Fair Volunteer Friend Other Web site Employee Other
If you selected Other Web site, Employee, or Other please list the Web site, employee name, etc:
EMPLOYMENT HISTORY
List all work experience beginning with the most RECENT position. Please complete even if a resume is attached.
May we contact your current employer?:
	Yes No
If "no" please explain:
Current Employer:
Employer Address:
Employer Phone Number:
Dates Employed:
From: (MM/DD/YYYY):
To: (MM/DD/YYYY):
Job Title:
Supervisor:
Reason for Leaving:
Salary:
Job Duties:
Name employed under if different from that above:
Employer Name:
Employer Address:
Employer Phone Number:
Dates Employed:
From: (MM/DD/YYYY):
To: (MM/DD/YYYY):
Job Title:
Supervisor:
Reason for Leaving:
Salary:
Job Duties:
Name employed under if different from that above:
Employer Name:
Employer Address:
Employer Phone Number:
Dates Employed:
From: (MM/DD/YYYY):
To: (MM/DD/YYYY):
Job Title:
Supervisor:
Reason for Leaving:
Salary:
Job Duties:
Name employed under if different from that above:
Employer Name:
Employer Address:
Employer Phone Number:
Dates Employed:
From: (MM/DD/YYYY):
To: (MM/DD/YYYY):
Job Title:
Supervisor:
Reason for Leaving:
Salary:
Job Duties:
Name employed under if different from that above:
Employer Name:
Employer Address:
Employer Phone Number:
Dates Employed:
From: (MM/DD/YYYY):
To: (MM/DD/YYYY):
Job Title:
Supervisor:
Reason for Leaving:
Salary:
Job Duties:
Name employed under if different from that above:
Complete only if driving is required by the position.
Is your Driver's License current?:
	Yes No
License #:
State:
Do you have any violations which appear on your motor vehicle report?:
	Yes No
If yes, please explain:
REFERENCES
(Please provide complete addresses for all references listed)
Reference #1 Name:
Phone:
Relationship:
Address:
City, State, ZIP:
Reference #2 Name:
Phone:
Relationship:
Address:
City, State, ZIP:
References #3 Name:
Phone:
Relationship:
Address:
City, State, ZIP:
CERTIFICATION OF APPLICANT
I hereby authorize Madonna Rehabilitation Hospital to investigate all statements made in this application and to contact all employers, schools, character references, governmental agencies, law enforcement agencies, health and human services and the state patrol and police department in order to obtain information on my background and history. I agree to sign consent forms if requested so that a full background and history can be obtained. I further agree and affirm that if there are any changes in my criminal history or any involvement with health and human services from the time I sign this application, I will provide updated information, in writing, to Madonna Human Resources Department. I understand that any false, misleading or incomplete responses in this application will be sufficient cause for not being hired and if employed, cause for discharge. I agree to submit to a pre-employment health screen given by Madonna Rehabilitation Hospital and I understand that successful completion will be a condition of my employment. I understand that my regular employment eligibility is subject to maintaining compliance with the Immigration and Reform and Control Act of 1986. Employment by Madonna Rehabilitation Hospital or any other participating employer does not create a contract between Madonna and its employees. Madonna reserves the right to terminate the employment relationship at any time, at will, for any reason. If I am hired, I agree to conform to the rules and regulations of the hospital. If I am hired, I agree to sign a consent form for an updated social history, background check, credit check, law enforcement history check, adult or child abuse registry check, or any other background or social history updated checks requested by Madonna.
Signature Agreement: