If you've been a brother, sister, son, daughter, father, or mother (or perhaps the oft-dreaded mother-in-law!), you know that family isn't all blue skies and roses. It takes hard work, but what a better thing to labor for than family!

At Meadowlark and Terry Lake Assisted Living, our hope is not only to provide a comfortable living environment, but to cultivate a friendly working environment. We hold our staff to a standard equivalent to the high honor of loving the family well. If you are interested in applying to work at either of our assisted living communities, please fill out and submit the form below, in it's entirety.*

Applicant Information
Name (First, M.I.) *
Name (First, M.I.)
Today's Date *
Today's Date
Address *
Address
Phone *
Phone
Date Available *
Date Available
Are You A QMAP? *
Do You Have Dependable Transportation? *
Are You A CNA? *
Do You Smoke? *
Do You Have Your First Aid Certificate? *
Are You Looking For FT or PT? (Hours) *
Do You Have A Current TB? *
Do You Have A Recent Flu Shot? *
Education
List the following for each that applies: Name, Address, Dates. Did You Graduate? Degree? If "other", please explain.
References
Please List Three Professional References
Name (1st Reference) *
Name (1st Reference)
Phone *
Phone
Address *
Address
Name (2nd Reference) *
Name (2nd Reference)
Phone *
Phone
Address *
Address
Name (3rd Reference) *
Name (3rd Reference)
Phone *
Phone
Address *
Address
Previous Employment
Phone *
Phone
Address *
Address
Supervisor Name *
Supervisor Name
Starting $ _____ / Ending $_____
From _____ To _____
May we contact your previous supervisor for a reference? *
Phone
Phone
Address
Address
Starting $ _____ / Ending $_____
From _____ To _____
May we contact your previous supervisor for a reference?
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Name as Electronic Signature *
Name as Electronic Signature
Today's Date *
Today's Date
Applicant Questionnaire
Please complete 2 of the following questions.