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OUACHITA COUNTY MEDICAL CENTER IS AN EQUAL OPPORTUNITY EMPLOYER. ALL PERSONNEL POLICIES ARE DETERMINED AND ALL APPLICATIONS FOR EMPLOYMENT ARE CONSIDERED WITHOUT REGARD TO AN INDIVIDUAL'S RACE, RELIGION, NATIONAL ORIGIN, SEX, AGE OR DISABILITY. IT IS THE POLICY OF OUACHITA COUNTY MEDICAL CENTER TO SELECT THE MOST QUALIFIED INDIVIDUAL BASED ON SKILL, ABILITY, EDUCATION, TRAINING AND EXPERIENCE NEEDED FOR THE QUALITY PERFORMANCE IN EACH POSITION.
Applicant Information
Last Name:
 First Name:
 Middle Init:
Today's Date: (mm-dd-yyyy)
Address:
 City:
 State:
Zip:
Phone Number:
Social Security #:
Draft Status:
Circle YES or No to the following questions
Are you a U.S. Citizen?: Yes  No
If No what type of Visa do you Possess?:
Have you ever been convicted of a felony?: Yes  No
If yes explain?:
Have you been discharged from a job?: Yes  No
If yes explain?:
Have you ever worked at Ouachita County Medical Center before?: Yes  No
If yes when?:
Have you ever worked at OCMC under another name?: Yes  No
If yes give name and date?:
Will you accept Full-Time work?: Yes  No
Will you accept Part-Time work?: Yes  No
Position?: Do you have experience?: Yes No
Shift/Hours you can work?: 7-3 3-11 11-7 Other: Date available for employment: (mm-dd-yyyy)
EDUCATION
Grade School:
Graduate Date: (mm-dd-yyyy)
Address:
City:
State:
Zip:
High School:
Graduate Date: (mm-dd-yyyy)
 Address:
City:
State:
Zip:
Average G.P.A.:
 Years Completed:
9 10 11 12 		 Special Training:
College/Nursing School:
Graduate Date: (mm-dd-yyyy)
Address:
City:
State:
 Zip:
Major:
Minor:
Degree:
Average G.P.A.:
Years Completed:
1 2 3 4 
Graduate School:
Graduation Date: (mm-dd-yyyy)
 Address:
City:
State:
 Zip:
Major:
Minor:
Degree:
 Average G.P.A.:
Technical Training:
Graduation Date: (mm-dd-yyyy)
 Address:
City:
State:
Zip:
Average G.P.A.:
Training:
Certification:
Please give the name of a person to notify in case of an emergency.
Name:
Address:
City:
State:
Zip:
Give names of the persons we may contact to verify your qualifications for the position
Name:
Occupation:
Organization:
Address:
City:
State:
Zip:
Phone:
Name:
Occupation:
Organization:
Address:
City:
State:
Zip:
Phone:
Work Experience: Give a complete record of employment and reasons for periods of unemployment during the past ten years.
Would you be willing to accept any duty in case of a need and/or emergency?: Yes No
Last Employee First
From: (mm-dd-yyyy)
 To: (mm-dd-yyyy)
 Company/Employer:
Address:
City:
State:
Zip:
Position Held:
Base Salary:
 Reason for Leaving:
From: (mm-dd-yyyy)
 To: (mm-dd-yyyy)
 Company/Employer:
Address:
City:
State:
Zip:
Position Held:
Base Salary:
Reason for Leaving:
From: (mm-dd-yyyy)
 To: (mm-dd-yyyy)
 Company/Employer:
Address:
City:
State:
 Zip:
Position Held:
Base Salary:
Reason for Leaving:
From: (mm-dd-yyyy)
 To: (mm-dd-yyyy)
 Company/Employer:
Address:
City:
State:
Zip:
Position Held:
Base Salary:
Reason for Leaving:
May we contact your current employer?: Yes No 
What office machines can you use?:
Typing Speed: (W.P.M)
Shorthand Speed: (W.P.M)
Professional Licenses, Registrations, and/or Certifications (Copy of Licensure must be submitted upon employment)
Type State Issued Date (mm-dd-yyyy) Number
Do you have any other areas of specialization or major interest?: Yes No
How did you hear of this position?:
PLEASE READ CAREFULLY
All hospital employees must be able to perform essential job functions. Employees may be required to undergo a medical examination at any time as a means of determining ability to perform duties. this may include, but is not limited to, a screening for alcohol and drug use. failure to undergo a medical examination when required will result in termination. I agree to the release of any records related to such medical examination to the hospital's administration.

Employment relationship is at will and may be terminated by either party at any time.

Affidavit: I certify that the answers given by me to the foregoing statements are true and correct without consequential omissions of any kind whatsoever. I agree that the hosiptal shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in the application. I authorize the hospital to perform a background investigation including but not limited to organizations and individuals listed above. I authorize the hospitals, schools, companies or persons named above to give any information regarding my employment and release them from all liability for any damage for issuing the information. I also understand an offer of employment will be conditioned on results of a medical examination, including a drug screen. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of Ouachita County Medical Center.

I agree to the above terms
I DO NOT agree to the above terms