Application

You can fill out application online (scroll down) or download file and fax or mail.

Download Employment Application (pdf)  Please download form, print, complete information.

Fax to: 434-239-0181

or

Mail to: Justin Berkley

The Madeline Centre, Inc., 18697 Old Forest Rd Lynchburg, VA 24502

or fill out online form below and submit:

Personal Information
  1. Name (Last, First MI)
  2. Street Address
    • City
    • State
    • Zip
    • Home Phone
    • Work Phone
    • Fax Number
  5. E-mail Address
    • SSN #
    • License Number
    • State
    • Exp
  7. Attach Your Resume
Employment Desired
  1. Position applied for
  2. How did you hear about this position?
  3. Date available for work
  4. Desired Hours
Education
  1. High School

    • Name And Address of School
    • Course of Study
    • Total Years of Study
    • Degree/Diploma
  2. Undergraduate College

    • Name And Address of School
    • Course of Study
    • Total Years of Study
    • Degree/Diploma
  3. Graduate/Professional

    • Name And Address of School
    • Course of Study
    • Total Years of Study
    • Degree/Diploma
  4. Other/Specify

    • Name And Address of School
    • Course of Study
    • Total Years of Study
    • Degree/Diploma
  5. List any seminars, classes, special training, or other education not listed above which may help qualify you for this position:
Employment Application
  1. Employer

     My Current Employer
  2. Address
    • City
    • State
    • Zip
    • Phone Number
    • Fax Number
  5. Supervisor
    • Start Date
    • End Date
    • Start Salary
    • End Salary
  8. Job Position(s)
  9. Essential Job Functions of Final Position



  10. E-mail Address of Supervisor
  11. Reason for Leaving
  1. Employer

     My Current Employer
  2. Address
    • City
    • State
    • Zip
    • Phone Number
    • Fax Number
  5. Supervisor
    • Start Date
    • End Date
    • Start Salary
    • End Salary
  8. Job Position(s)
  9. Essential Job Functions of Final Position



  10. E-mail Address of Supervisor
  11. Reason for Leaving
  1. Employer

     My Current Employer
  2. Address
    • City
    • State
    • Zip
    • Phone Number
    • Fax Number
  5. Supervisor
    • Start Date
    • End Date
    • Start Salary
    • End Salary
  8. Job Position(s)
  9. Essential Job Functions of Final Position


  10. E-mail Address of Supervisor
  11. Reason for Leaving
  1. Employer

     My Current Employer
  2. Address
    • City
    • State
    • Zip
    • Phone Number
    • Fax Number
  5. Supervisor
    • Start Date
    • End Date
    • Start Salary
    • End Salary
  8. Job Position(s)
  9. Essential Job Functions of Final Position



  10. E-mail Address of Supervisor
  11. Reason for Leaving
Additional Information
  1. List any professional experiences or memberships in any business or civic activities or organizations which are relevant to this position.
  2. List any languages other than English that you can speak, read or write that could be of benefit to the position applied for:
  3. Language
    • Speaking
       Fluent Good Fair
    • Reading
       Fluent Good Fair
    • Writing
       Fluent Good Fair
  5. Language
    • Speaking
       Fluent Good Fair
    • Reading
       Fluent Good Fair
    • Writing
       Fluent Good Fair
  7. Language
    • Speaking
       Fluent Good Fair
    • Reading
       Fluent Good Fair
    • Writing
       Fluent Good Fair
  9. If hired, can you provide proof of U.S. citizenship or proof of your legal right to work in the U.S.?
     Yes No
  10. If driving is a requirement of the position applied for, have you in the last 7 years been convicted of Driving Under the Influence “(DUI)”
     Yes No
  11. If hired, do you have a reliable means of transportation to and from work?
     Yes No
  12. If hired, would you be able to travel or work overtime as needed?
     Yes No
  13. Have you ever been convicted of a felony or misdemeanor? If Yes, Explain in space below:
     Yes No
  14. Are you willing to drive 50 miles if needed to visit clients? (for in-home therapists.)
     Yes No
  1. AUTHORIZATION:
    I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

    I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

    I also understand and agree that no representative of The Madeline Centre, Inc. has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

  2.  I understand the terms set by The Madeline Centre, Inc.