Contact form

Martha Jefferson House is an equal opportunity employer and does not discriminate against any employee or applicant because of age, color, disability, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information. Martha Jefferson House has a policy to provide qualified applicants and associates with necessary reasonable accommodations as required by Federal law. This policy of nondiscrimination extends to all terms, conditions and privileges of employment and to all personnel actions.

Personal Information

Are you at least 16 years of age or older?

Have you ever worked at MJH before?

Position Information

Type of employment desired:

Full TimePart TimePRN

How did you hear about us?

Were you referred by a current employee?

Employment Information

Currently employed?

Current or most recent position

Previous Position

Previous Position 2


Reference 1

Reference 2

Reference 3

US Military Service

Please Answer the Following Questions:

For purposes of compliance with The Immigration Reform and Control Act of 1968, are you legally eligible for employment in the United States?

Have you any misdemeanor/felony convictions or pending charges, other than minor traffic violations?

If yes, explain:


  1. Except as other specified herein, I authorize Martha Jefferson House to contact my former employers and references listed on this application, and I authorize such individuals to release information requested by Martha Jefferson House.

  2. I certify that the information contained in my application materials are true and correct to the best of my knowledge and belief, and I understand that if employed, false statements on this application will be considered grounds for dismissal.

  3. I understand that all employees of Martha Jefferson House are at-will employees and both the employee and Martha Jefferson House are free to terminate the employment relationship at any time at their discretion. No supervisor or other Martha Jefferson House employee has the authority to alter this relationship.

  4. I understand that as a condition of my employment with Martha Jefferson House, I may, from time to time, be asked to undergo drug screening at Martha Jefferson House’s expense, and I agree to submit to drug or other medical tests as required by Martha Jefferson House during the course of my employment.

  5. In addition to drug screening I understand that if employed, I will be required to undergo an initial intradermal PPD or chest x-ray for tuberculosis screening. I further understand that the results of my tuberculosis screening will be disclosed to the facility and I do so authorize.

  6. I further understand that if offered employment, I will be required, in accordance with The Immigration Reform and Control Act of 1968, to produce proof that I am eligible to work in the United States.

I certify that I have read and agree with these statements.

Note to Applicant: This application for employment shall be considered active for a period of time not to exceed 6 months. Applicants wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.