Ohio County Hospital

Departments / Services

Giving Opportunities

Employee Application Step 1 - Personal Information	Step # 1 of 7

Date Available for Employment:	(format: mm/dd/yyyy)
Salary Requirement:	Hourly Yearly

Prefix:
First Name:	*
Middle Initial:
Last Name:	*
Suffix:		Previous Address (if less than 5 years at current)
Social Security Number:		Previous Address (if less than 5 years at current)
Address:		Address:

City:		City:
State:		State:
Postal Code:		Postal Code:
Years at this Address:
Home Phone:	*	Primary Email:
Work Phone:		AlternateEmail:
Best time to call:
Fax:		Are you legally allowed to work in the US? yes no
May we call you at work?	yes no	Have you ever been employed by OCH? yes no
Do you have any relatives employed at OCH? yes no		Have you ever been convicted of any crime? yes no
Have you ever been listed as debarred? yes no		Are you charged with any violations now? yes no

* Required

Employee Application Step 2 - Position & Availability	Step # 2 of 7

If you are applying for a specific open position or would like to be considered for multiple open positions, please select the position(s) that you are applying from the following list:
ARNP Emergency Medicine Physician Family Medicine Physician MT or MLT Orthopedic Surgeon RN Staff Nurse RN Staff Nurse Emergency Dept RN Staff Nurse Emergency Dept Social Worker
If you are forwarding this application for consideration when future openings occur, please list the type of positions you would like to be considered for below:

Desired Work Schedule:
Status:	Full Time	Part Time	Relief	Any
Shift:	Days	Evenings	Nights	Alternating	Any
Work Days:	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Would you consider other work schedule parameters? yes no

Employee Application Step 4 - Education	Step # 4 of 7

EDUCATION		Did you graduate? (if not, indicate grade completed)	When? (year)	Name of School & Location

	High School	yes no grade:
	Major Subjects

	College	yes no grade:
	Major Subjects

	School of Nursing	yes no grade:
	Major Subjects

	Special Schooling or Training	yes no grade:
	Major Subjects

Honors Received:

Employee Application Step 7 - Submit Application

Step # 7 of 7


Ohio County Hospital - Employee Application Employee Statement Ohio County Hospital is an equal opportunity employer. It is policy that all individuals are entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, or disability as required by state and federal law. The Hospital is committed to this policy. All appropriate steps are taken to ensure equal opportunity in employment with respect to all personnel actions, including, but not limited to: recruiting, hiring, compensation, benefits, education and promotion / advancement opportunities. Applicant's Statement I certify that the information I have provided on this application is true and complete to the best of my knowledge, In the event of employment, I understand that false or misleading information given on this application or subsequent interview(s) may result in termination of employment. I grant permission to Ohio County Hospital to contact any of the employers, supervisors, managers, educational institutions, and/or references listed in this application unless I have indicated to the contrary in the appropriate fields on this application. I authorize my former and/or current employer(s) to release information pertaining to my work record, work habits, and my work performance while in their employment. I understand that Ohio County Hospital may, and hereby authorize it to solicit information regarding my character, felony record, driving record, previous employment, and/or similar background information. I understand that any employment offer is contingent upon a background check and/or successful completion of any other conditions that may be required. I understand that my employment is contingent upon proof of identity and verification of eligibility for employment in the United States, in accordance with the Immigration Reform Act or 1986. I understand that neither this application nor any verbal offer of employment is an employment contract. I further understand that any employment offered to me is terminable at will. This means I can quit at any time and Ohio County Hospital can terminate my employment at any time, with or without cause and without advance notice. Confirmation
Yes, I have read and understand the above, and hereby certify that the facts I have provided in my employment application are true and complete. Please submit my application.
No, I do not agree with the above Applicant's Statement or the other policies contained in this application. Please cancel application.

Employment Application - Reference Information

Employment Application - License or Certificate Information

Employment Application - Employer Information


Comments regarding lapses, if applicable
Did you list all of your employers? yes no
Have you ever been discharged from a job or forced or asked to resign? yes no
Long Range Occupational Goals:
May we contact your current employer? yes no

Employee Application Step 3 - Employment History	Step # 3 of 7

List all previous employers for whom you have worked, started with most recent employer. Explain any lapses between times when employed.

Employee Application Step 5 - Licenses and Certifications	Step # 5 of 7

Professional Licenses and Certifications:

Employee Application Step 6 - References and Attachments	Step # 6 of 7