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I certify that the information provided in this employment application is true, complete and submitted by me, and I understand that any false information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment if discovered at a later date. I agree to immediately notify the hospital if I should be convicted of a felony or any crime involving dishonesty or a breach of trust while my application is pending or during my period of employment, if hired.

Virginia Gay Hospital is an equal employment opportunity employer. No person is unlawfully excluded from consideration for employment because of race, color, religious creed, national origin, ancestry, gender, age, veteran status, marital status, sexual orientation, transgender identity, or physical challenges. This policy applies not only to recruitment and hiring practices, but also in the areas of placement, promotion, transfer, rate of pay, and termination. No question on this application is intended to secure information to be used for such discrimination. I agree with this statement: *

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination and such future examinations as may be required of this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physician examination which relates to the essential duties I would be required to perform. I agree with this statement: *

I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may terminate for any misstatement or omission of fact appearing on this application form. I agree with this statement: *

If employed I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility of employment. I agree with this statement: *