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Position applying for:
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First Name:
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Have you ever been employed by Ohio County Healthcare?:
Do you have any relatives employed by Ohio County Healthcare?:
Have you ever been convicted of a crime?:

Education

License/Certification/Registration Name:
License/Certification Date:
Identification Number:
Issuing Body:
Are there any restrictions on your licensure/certification/registration? Have you ever had action taken against your licensure/certification/registration?:
What is your highest level of completed education?:
Name of school:
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Are you currently enrolled in and/or attending classes?:
Completion date:
Name on Certificate:

Prior Employment

Employer 1

Company name:
Position:
Employed From:
Employed To:
Reason for leaving:
Ending salary:
Supervisor name:
May we contact this employer for a reference?:

Employer 2

Company name:
Position:
Employed From:
Employed To:
Reason for leaving:
Ending salary:
Supervisor name:
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Employer 3

Company name:
Position:
Employed From:
Employed To:
Reason for leaving:
Ending salary:
Supervisor name:
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References

Name of professional reference (Include relationship, phone number, organization and email address):
Name of professional reference (Include relationship, phone number, organization and email address):
Name of professional reference (Include relationship, phone number, organization and email address):
Attach resume:
Attach certifications:

Applicant’s Statement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. The applicant understands that neither this document nor any offer of employment from the employer constitute an employment contract unless a specified document to that effect is executed by the employer and employee in writing. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Background Verification Disclosure

As part of the employment process, Ohio County Healthcare may obtain a Consumer Report and/or an Investigative Consumer Report. The Fair Credit Reporting Act as amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for purposes of employment only, a Consumer Report may be made which may include information about your character, general reputation, personal characteristics, or mode of living. Upon written request, additional information as to the nature and scope of the report, if one is made, will be provided in the event the report contains information regarding your character, general reputation, personal characteristics, or mode of living.

Authorization and Release

During the application process and at any time during any subsequent employment, I hereby authorize the selected background check company, on behalf of Ohio County Healthcare, to procure a Consumer Report which I understand may include information regarding my character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from courts record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

I acknowledge I am responsible for complying with Ohio County Hospital Corporation’s compliance and organizational policies. I realize that, if employed, I have a role in the overall effectiveness of the compliance program including reporting suspected compliance violations.

I accept the Terms & Conditions

Ohio County Healthcare

Ohio County Healthcare is a non-profit Joint Commissioned accredited health system which provides a wide range of hospital, primary care and specialty physician services.

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Ohio County Healthcare offers a broad range of healthcare across a diverse landscape.

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