_________________________________________________________________________________

Name Date

BLUE RIDGE MEDICAL CENTER

Application For Employment

All statements made by applicants for employment on the application form will be checked for

accuracy. We offer equal employment opportunities to all persons without discrimination on

the basis of race, color, religion, age, sex, national origin, citizenship status, genetic infor-

mation, physical or mental disability, or past, present or future service in the Uniformed

‘services of the U.S., or any other legally protected status. The use of this form does not mean

there are positions open and does not obligate us in any way.

Blue Ridge Medical Center is an equal opportunity employer.

July 2020

Applicants should send application and re sume to:

HR@brmedical.com, Human Resources – 4038 Thomas Nelson Hwy, Arrington, VA 22922

or fax to Attn: HR at (434) 263-7388.

PERSONAL INFORMATION

Name ___________________________________________ Home phone ___________________________

Email ___________________________________________ Cell phone ____________________________

Present Address _________________________________________________________________________

_______________________________________________________________________________________ (City) (State) (Zip)

If at present address less than one year, please give previous address_______________________________

_______________________________________________________________________________________

Are you at least 18 years of age? Yes No (Employment is subject to verification of minimum legal age.)

Can you produce documented proof of your identity and eligibility for employment in the United States”?

Yes No (Examples: driver’s license, Social Security card, birth certificate, passport, and/or immigration

Position (s) applied for ___________________________________ ___________________________________

How soon could you report to work? ________________________

Type of employment desired Full-Time Part-time Temporary Rate of pay expected ______________

What days and hours, if part-time? Days ______________________________ Hours ______________________

EDUCATION

Type Of School Name and Address of

School

Courses Majored in Circle Last Year Completed

Graduate?

Show Degree

High School 9 10 11 12

College 1 2 3 4

Post Graduate

Please provide any additional information such as certifications, special skills, training, experience, equipment operation, or other qualifications you feel will be helpful to us in considering your application.

Have you applied for a job here before? Yes No Have you worked for us before? Yes No

How did you hear about this job? Employee Referral Former Employee Newspaper ad

Walk-In Other ___________________________________

Have you ever been bonded? Yes No Have you ever been refused a bond? Yes No

If yes, state reason and date______________________________________________________________

Have you ever been convicted of a felony Yes No If yes, please explain ___________________

______________________________(a conviction does not necessarily disqualify you from employment.)

Have you ever been discharged or requested to resign from a position? Yes No

Are you employed now? Yes No If yes, may we contact your present employer Yes No

Have you ever held a position of trust (handling money or confidential material)? Yes No

If yes, describe _________________________________________________________________________

Do you have reason to believe you would have difficulty meeting BRMC’s work schedule? Yes No

PRIOR WORK EXPERIENCE (Start with present or most recent employer and complete in full)

1. Name and address of most recent employer Telephone number

Immediate Supervisor (Name & position) Starting Date

Ending Date

Job Title & Duties Starting Salary

Ending Salary

Reason for Leaving May we contact this employer Yes No

2. Name and address of former employer Telephone number

Immediate Supervisor (Name & position) Starting Date

Ending Date

Job Title & Duties Starting Salary

Ending Salary

Reason for Leaving May we contact this employer Yes No

3. Name and address of former employer Telephone number

Immediate Supervisor (Name & position) Starting Date

Ending Date

Job Title & Duties Starting Salary

Ending Salary

May we contact this employer Yes No Reason for Leaving

REFERENCES (Do not include relatives)

Name __________________________Address _______________________________Telephone_______________

Name __________________________Address _______________________________Telephone_______________

Name _________________________ Address _______________________________Telephone_______________

JOB APPLICANT AGREEMENT AND CERTIFICATION

“I certify that the information given by me in this application is true in all respects, and I agree that if the infor-mation given is found to be false in any way, it shall be considered sufficient cause for denial of employment or discharge. I authorize the use of any information in this application to verify my statements, and I authorize past employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages because of having furnished such information.”

“I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between BRMC and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. And I understand that no such promise or guarantee is binding upon the company unless made in writing. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and that the company retains the same right.”

“If I am offered employment, I agree to submit to a physical examination, including drug screen, whenever re-quested, and I understand my becoming employed and/or my continued employment are subject to the results of any physical examination/drug screen related to my job duties in accordance with company policies and proce-dures.”

“I understand that any offer of employment is contingent upon the results of a background check specific to the medical industry. The check will be conducted as soon as possible after employment is accepted.“

“I understand that if employed, policies, and rules which are issued are not conditions of employment and that BRMC may revise policies or procedures in whole or in part, at any time.”

“I understand that this application will be kept on active file for 90 days from the date completed, after which time I would have to reapply in accordance with established company procedures.”

________________________________________________________________________________

(Signature of Applicant) (Date)

Conflict of Interest Disclosure Form

The Center expects its employees to conduct business according to the highest ethical standards of conduct. Employees are expected to devote their best efforts to the interests of The Center. Business dealings that appear to create a conflict between the interests of The Center and an employee are unacceptable. The Center recognizes the right of employees to engage in activities outside of their employment which are of a private nature and unrelated to our business. However, the employee must disclose any possible conflicts so that The Center may assess and prevent potential conflicts of interest from arising. Such a conflict would arise when an employee, board member or agent, or any member of his or her immediate family, his or her partner, or an organization which employs or is about to employ any of the parties indicated herein, has a financial or other interest in the firm selected for the award. An employee and his/her immediate family may not own or hold any significant interest in a supplier, customer or competitor of The Center, except where such ownership or interest consists of securities in a publicly owned company and that securities are regularly traded on the open market.

Please answer the following questions to the best of your knowledge:

Yes No Do you or any member of your immediate family have a significant or influential relationship with (or a financial interest when aggregated for your immediate family in) The Center’s Board of Directors (see list below)? Yes No Do you hold any position or appointment as a Director (Executive or Non- executive) in any company, whether or not this company does business with The Center? Yes No Are you aware of any other circumstances that could constitute a conflict of interest if you were chosen to be hired for a position at The Center?

If you have answered 'YES' to any of the questions above, please give full details overleaf

Board of Directors Weeta Bell-Phillips Andrew Hodson, MD Deanna Shaver Bruce Bertelsen Esther Larkin William “Jr.” Thompson Stephen Colgate Bill Martin Jennifer Turner Judy Greenberg Roberta Pickett Dennis Vrooman Jerry Gress

Please give details of the relationship or financial interest with member(s) of The Center’s Board of Directors. Directorship position: Give date of appointment, name & address of company and state if company is involved IN ANY WAY with The Center. Give details of any other conflict of interest that may exist if you are chosen to be hired for a position at The Center.

I acknowledge that I have read and understand The Center’s policy on Conflict of Interest. I confirm that this form has been completed to the best of my knowledge and that the information contained on this form is true and correct. I understand that if hired and the information is later found to be false I may be subject to disciplinary proceedings. Signature of Applicant: Date: