Countryside Home Application for Employment

703 N Main St. Madison, NE 68748

Skilled Nursing Facility, Assisted Living & Rehabilitation & Aquatics Center

Personal Information


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High School/GED

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Professional References: List at least two professional references.


Experiences: Please give a complete record of all employment. Start with your most recent.




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Military Services:
Applicant's Statement:

I understand that any false or incomplete statements on this application or any other form that I complete shall be sufficient cause for rejection for employment or immediate discharge when discovered.

I authorize investigation of all statements contained in this application for employment as may be necessary for arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

I understand if I am offered a position, it may be contingent on successfully passing a post-offer drug test, physical and criminal background check. All positions require various registry checks as well. See Countryside Home hiring Screening Policy and Procedure for New Employee.

We are an equal opportunity employer and do not discriminate because of race, creed, ancestry, color, religion, sex, national origin, age, marital status, veteran status or disability.

Policy Statement

This criteria is established to ensure that all new employees meet state standards for employment in a Nursing Home Facility and/or Assisted Living Facility. All requirements must be met before an employee begins employment at Countryside Home Nursing Facility and/or Assisted Living Facility.


  1. All applicants will be checked by the State of Nebraska Adult Protective Services and Child Protective Services.
  2. All applicants will have criminal background checks.
  3. All applicants will be checked by Sexual Abuse Registry of Children and Adult.
  4. All applicants will be screened for HHS-OIG exclusion status. This excludes individuals from all Federal care programs.
  5. All applicants will have license reviewed when appropriate for the position.
  6. All applicants will have driving records checked when appropriate.
  7. All applicants will take a physical by a designated physician of Countryside Home; which will include a drug screen and TB screen.
  8. All applicants will be screened initially and annually by filling out the form MIL TC-1500-AL. All care staff in the assisted living facility will file a felony misdemeanor form annually upon Medicaid waiver re-certification.

Please answer these questions to prove you are a human.