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1 dpmofpo D App : T h nky ouf o y ou nc n P o E du on C pf V ym d C T hd p m of P o C h b n n g p of hho p mf o w o 4 +y T h n o d nf o m onw p o dy ouw h h pp onp o P you w b und d opm nd f o h om ng W ookf o w d o ngy ou pp on S hou dy ouh qu on bou ou p og mo h pp onp o, p dono h o o m ( 9 ) 5 3 3o ( 9 ) 5 9o ( 9 ) 5 4 S n y, R C yj M n, M D R u m / Adm oncoo d n o C n P o E du ons up o, ACPE ( 9 ) m n@ p f y om

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3 Cn Po Eduon Appon CAPE FEAR VALLEY MEDICAL CENTER PROGRAM FOR CLINICAL PASTORAL EDUCATION 38 Own D Fy, NC 2834 PO Box T: (9) 5-33 Fx: (9) 5- CPE Pogm Add by Th Aoon of Cn Po Eduon, In W Cou Squ #325 Du, Gog (44) wwwpdu I Nm: D: Cu Add: Cy S Zp E-m: Tphon#: (H): (O): (C): II Pogm of CPE fo whh you ppyng: L I Fu-Tm CPE: (Summ Inhp) Y 2 Exndd CPE: (Spng Inhp) o (F Inhp) Y L II Fu-Tm CPE: (Summ) Y 2 Exndd CPE: (Spng) o (F) Y 3 A you ppyng o oh CPE? Y No III Enom: Enom hough Thoogy o Dy Shoo Y No 2 Enom hough Pogm Fo Cn Po Eduon Y No

4 IV E nd Eduon Infomon: Dnomon Odnd D 2 Aoon, Confn, Do, Pbyy, Synod 3 If you po of o huh, off w of you pn o ngg n CPE nng? 4 I CPE qud o ommndd by you dnomon o mny fo gduon o odon? Y/N Ah ddon xpon 5 Eduon (Hgh Shoo dg o GED qud) Cog Mjo Dg D b Smny Mjo Dg D Gdu Wok Mjo Dg D Pou CPE o upd ounng xpn: Ah ddon pp, f ny Inuon Supo D 7 Wok xpn: Ah ddon pp, f ny Loon Poon D V Wn nfomon o b hd: W n uobogphy y (3-5) pg, ng-pd, ypd whh nud h foowng: A dpon of h fmy n whh you gw up; b A dpon of you u fmy; A dpon of gnf gou xpn n you f, wh p fn o h umn uoundng you don fo fu-m huh oon;

5 d A dpon of ny o o uu nfun upon you whh h bn gnf n you f; A dpon of you u go n f, boh pofon nd pony; f Duon of h knd of xpn whh mo ky o mk you nxou o unomfob nd you h wy of pondng o uh xpn; g Expon o umn whh h nougd you o ppy fo h duon nd nng h You undndng o xpon of CPE nd wh you wh o hppn n h nng xpn L you ngh nd wkn, you undnd hm h m fo ng CPE pogm 2 If you h hd pou CPE, nud op of boh you Fn Euon() nd ho of you Supo() If you h hd n Admon' Snng Iw fo CPE, nud opy of h po 3 Db n nd n whh you mpd o mk po pon o fmy o pon xpnn g 4 Ind f you h ough ounng o pyhohpy Ung you own don db wh h xpn m o you 5 Ind how you pn o fnn you CPE nng VI Rfn: P wo fn, on fom you fh goup nd h oh fom n dm ox Th fh goup fn n b fom you po, bb, bhop o gy pon who h known you n h po o Th dm fn houd b fom pofo o do who h known you og o mny ud P nd h ommndon fom o h fn Thy houd omp nd un o you n gnd nd d nop M h wo nop, $3 ppon f nd you ompd ppon fom o: R Cy J Mn CPE Admon Coodo Cp F Vy Md C Pogm Fo Cn Po Eduon 38 Own D Fy, NC 2834 PO Box

6 ETHICAL CONDUCT AFFIDAVIT I fy h: () no onon, d pn (nudng fn o non) o o on ng fom omp of unh o fonou ondu h bn mpod on m, nd no omp gn m fo unh o fonou ond u pndng n, m n,, mpoym o noh pofon ognzon foum; nd (b) I h n gnd, bn nfd o md, no ngod m fom po on fo on d o unh o fonou ondu App Sgu: If h bo nno b fd, p h n ou of h omp nudng h foum, h hg, nd h fn ouom Pod h nm of pop nod n h po h you uhoz o pod fu nfomon o Cp F Vy p Po on no n uom b o bng pd n h CPE pogm Eh uon w b ud on own m by ou Admon Comm nd oh onu fom ou Pofon Adoy Goup, Lg Dpm, nd Humn Rou, ndd Don of h Admon Comm fn nd no ubj o pp I undnd h ondon of my ppon nd of my mpoym, houd I b hd, h I w pod h Pogm fo Cn Po Eduon hough h CPE upo wh my no of ny u unod om p o of ny fuu om p of unh o fonou ondu fd gn m I g o pod h n w ng n my f hon nd w u bm ny nfomon qud gdng h ngon, djudon, dm o m of uh omp Fu o po o p od u, fu nd uhfu nfom on my b gound fo nufyng my ppon o fo dm fom h Pogm of Cn Po Eduon App Sgu: READ CAREFULLY BEFORE SIGNING I fy h h nf omon ond n h ppon nd hm u I fuh undnd h ffon of nfo mon o nomp m hn w u n non of h ppon I g h xmon nd fon of my mpoym o pou duon, xp pn o g,, x, oo, d, on ogn, m u o dby, my b md nd ud o m y ppon u I, hfo, uhoz my fom mpoy, pon d fn nd oh p on o ognzon d o po d h nfomon nd I onnd fom ny by n onnon hw h I o undnd h h ppon f no fundb App' Sgu: D: App Nm

7 Rfn fo: (Nm of App) Nm: Th Rfn G P u h pp on h foowng by hkng h ppop box: Nm of Ognzon: You Poon: Mng Add: Co Phon ( ) E-M: How ong h you known h pp? In wh py? Sgu: D: Mn Compn Iu Aby Ipon Sk Emoon Muy Rby I Gn Knowdg Ex Vy Good Good Wk Vy Wk If you h ny quon, p o R Cy Mn, Cp F Vy CPE Admon Coodo, (9) 5-33 o (99) Thnk you fo ppng n ou m of h pp' dn fo Cn Po Eduon P dd ny omm gdng h pp po, ud nd pon P un you ompd fn o h pp n d nd gnd nop

8 Rfn fo: (Nm of App) Nm: Th Rfn G P u h pp on h foowng by hkng h ppop box: Nm of Ognzon: You Poon: Mng Add: Co Phon ( ) E-M: How ong h you known h pp? In wh py? Sgu: D: Mn Compn Iu Aby Ipon Sk Emoon Muy Rby I Gn Knowdg Ex Vy Good Good Wk Vy Wk If you h ny quon, p o R Cy Mn, Cp F Vy CPE Admon Coodo, (9) 5-33 o (9) 33-2 Thnk you fo ppng n ou m of h pp' dn fo Cn Po Eduon P dd ny omm gdng h pp po, ud nd pon P un you ompd fn o h pp n d nd gnd nop

9 BACKGROUND CHECK DISCLOSURE In h of mnng h fy nd uy of ou uom, mpoy, nd popy, Cp F- Cumbnd Cy Hop (h Compny ) w od onum po ( bkgound hk) on you n onnon wh you mpoym ppon, nd f you hd, o f you dy wok fo h Compny, my od ddon bkgound hk on you fo mpoym pupo Th Compny my od n ng onum po An ng onum po bkgound hk h nud nfomon fom pon w (xp n Cfon, wh h m nud bkgound hk wh nd whou pon w) Th mo ommon fom of ng onum po n ngon o you mpoym hoy Th bkgound hk ompny, P Ey, In, w pp h bkgound po fo h Compny P Ey, In od 9 Noh Wg Ln, Su 22, Wnu Ck, CA 94598, nd n b hd o f Th py po fo P Ey In my b found wb wwwpynom Th bkgound hk my on nfomon onnng you h, gn puon, pon h, mod of ng, mn hoy, d wohn, d py nd d ndng Th yp of nfomon h my b odd nud, bu no md o: mn, pub, duon, my nd moo h od hk; fon wh h Dpm of Tnpoon; fon of po mpoym nd nom; fn, nng, nd fon hk; d po; nd So Suy numb fon Infomon my b obnd fom p nd pub od ou (nudng nddu, opoon, pnhp, w nfom gn, nuon, hoo, d buu, nng gn nd p nd p mpoy), nd fo ng onum po, fom pon w wh you o, fnd nd nghbo Suh nqu my qu nfomon gdng nn of hm, on, hf o fud You h h gh o qu mo nfomon bou h u nd op of n ng onum po, f ny, by ong h Compny 9 W Wg Ln, Su 22, Wnu Ck, CA STATE SPECIFIC NOTICES If you o wok fo h Compny n ny of h d bow, p no h foowng: CONNECTICUT: Th Compny w ony obn nd u nfomon bou you d hoy nfomon fo mpoym pupo f h nfomon uby job-d whn h mnng of ppb w Th pupo nud ng whh ndd qufd fo n poon You my qu mo nfomon by ong h Compny CALIFORNIA: You h gh o w h f h P Ey, In h wh you nfomon, nd od opy of h f, upon ubmng pop dfon nd pyng opyng o, by omng o h off, dung nom bun hou nd on onb no, o by m You o my k fo f-ummy by phon P Ey, In n nw quon bou nfomon n you f nudng ny odd nfomon If you om o h off n pon, noh pon n jon you, o ong h pon n how pop dfon Th Compny w ony obn nd u nfomon bou you d hoy nfomon ony owd by ppb w You my qu mo nfomon by ong h Compny MAINE: If you o h Compny, you h h gh o know whn 5 bun dy whh h Compny odd n ng onum po bou you, nd f o, o o h dd nd phon numb of h n off fo P Ey, In You h h gh o k P Ey, In fo opy of ny uh po nd o pompy h opy fom P Ey, In MARYLAND: Th Compny w ony obn nd u nfomon bou you d hoy nfomon fo mpoym pupo f h nfomon uby job-d whn h mnng of ppb w Th pupo nud o whh ndd qufd fo n poon You my qu mo nfomon by ong h Compny Pg

10 MASSACHUSETTS: If you o h Compny, you h h gh o know whh h Compny odd n ng onum po bou you You o h h gh o k P Ey, In fo opy of ny uh po MINNESOTA: You h h gh n mo umn o ubm wn qu o P Ey, In fo omp nd u dou of h u nd op of ny onum po h Compny odd bou you P Ey, In mu pod you wh h dou whn 5 dy f p of you qu o h po w qud by h Compny, whh d NEW JERSEY: You h h gh o ubm qu o P Ey, In fo opy of ny ng onum po h Compny odd bou you NEW YORK: If you o h Compny, you h h gh o know whh h Compny odd onum po o ng onum po bou you Shown bo h dd nd phon numb fo P Ey, In You h h gh o o P Ey, In o np o opy of ny uh po A opy of A 23-A of h Coon Lw podd bow OREGON: Th Compny w ony obn nd u nfomon bou you d hoy nfomon fo mpoym pupo f h nfomon uby job-d whn h mnng of ppb w Th pupo nud ng whh ndd qufd fo n poon You my qu mo nfomon by ong h Compny WASHINGTON STATE: If you ubm wn qu o h Compny, you h h gh o omp nd u dou of h u nd op of ny ng onum po h Compny odd bou you You d o h dou whn 5 dy f h d you qu d o w odd h po, whh You o h h gh o qu wn ummy of you gh und h Whngon F Cd Rpong A Th Compny w ony obn nd u nfomon bou you d hoy nfomon fo mpoym pupo f h nfomon uby job-d whn h mnng of ppb w Th pupo nud ng whh ndd qufd fo n poon You my qu mo nfomon by ong h Compny BACKGROUND CHECK AUTHORIZATION Af fuy dng h Bkgound Chk Dou nd Auhozon fom, I uhoz h Compny o od my bkgound hk, nudng ng onum po I undnd h h Compny my y on h uhozon o od ddon bkgound hk, nudng ng onum po, dung my mpoym whou kng m fo my uhozon gn, owd by w I o uhoz of h foowng o do o P Ey, In nd g nfomon bou o onnng m, nudng bu no md o: my p o p mpoy; nng nuon, nudng og nd un; w nfom nd oh fd, nd o gn; fd, nd o ou; h my; d buu; ng f; moo h od gn; oh p nd pub o poo of nfomon; h Dpm of Tnpoon, h my nd ny oh pon, ognzon, o gny wh ny nfomon bou o onnng m Th nfomon h n b dod o P Ey, In nd g nud, bu no md o, nfomon onnng my mpoym nd nng hoy, duon, d hoy, moo h hoy, mn hoy, my, pofon d nd n, nd my nud nqu gdng wok ompnon, hm, on, hf o fud Pg 2

11 I g h, owd by w, h Compny my y on h uhozon o od bkgound hk fom ompn oh hn P Ey, In whou kng m fo my uhozon gn I o g h opy of h fom d k h gnd ogn I pom h of my pon nfomon on h fom u nd o nd undnd h dhony w dqufy m fom ondon fo mpoym wh h Compny, o f I m hd o dy wok fo h Compny, h my mpoym my b md L Nm F Mdd Mdn Nm Y Ud Oh Nm Y Ud So Suy Numb D Ln Numb S Oh D Ln Hd n P 5 Y (nud ) FOR IDENTIFICATION PURPOSES ONLY: D of Bh / / (Moh/Dy/Y) P S Add Cy/S/ZIP Po S Add Cy/S/ZIP Rd Add Whn Sn Y (u p h ndd) Fom / / (Moh/Dy/Y) To / / (Moh/Dy/Y) Po S Add Cy/S/ZIP Fom / / (Moh/Dy/Y) To / / (Moh/Dy/Y) / / Sgu D: (Moh/Dy/Y) If you o wok fo h Compny n Cfon, Mnno o Okhom: Chk h box f you woud k f opy of you bkgound hk po: C Aou Numb: Cp F-Cumbnd Cy Hop **Rqud by: Ruby Rodguz **Em: od2@pfyom Pg 3

12 P nfomon n pno, wwwonumfnngo/nmo o b I Conum Fnn Poon Buu, 7 G S NW, Whngon, DC 2 A Summy of You Rgh Und h F Cd Rpong A Th fd F Cd Rpong A (FCRA) pomo h uy, fn, nd py of nfomon n h f of onum pong gn Th mny yp of onum pong gn, nudng d buu nd py gn (uh gn h nfomon bou hk wng ho, md od, nd hoy od) H ummy of you mjo gh und h FCRA Fo mo nfomon, nudng nfomon bou ddon gh, go o wwwonumfnngo/nmo o w o: Conum Fnn Poon Buu, 7 G S NW, Whngon, DC 2! You mu b od f nfomon n you f h bn ud gn you Anyon who u d po, noh yp of onum po o dny you ppon fo d, nun, o mpoym - o o k noh d on gn you mu you, nd mu g you h nm, dd, nd phon numb of h gny h podd h nfomon! You h h gh o know wh n you f You my qu nd obn h nfomon bou you n h f of onum pong gny (you ''f dou'') You w b qud o pod pop dfon, whh my nud you So Suy numb In mny, h dou w b f You d o f f dou f:! pon h kn d on gn you bu of nfomon n you d po;! you h m of dy hf nd p fud n you f;! you f on nu nfomon u of fud;! you on pub n;! you unmpoyd bu xp o ppy fo mpoym whn dy In ddon, onum d o on f dou y 2 moh upon qu fom h onwd d buu nd fom onwd py onum pong gn S wwwonumfnngo/nmo fo ddon nfomon! You h h gh o k fo d o Cd o num umm of you d-wohn bd on nfomon fom d buu You my qu d o fom onum pong gn h o o dbu o ud n d popy on, bu you w h o py fo In om mogg non, you w d o nfomon fo f fom mogg nd! You h h gh o dpu nomp o nu nfomon If you dfy nfomon n you f h nomp nu, nd po o h onum pong gny, h gny mu ng un you dpu foou S wwwonumfnngo/nmo fo n xpon of dpu podu! Conum pong gn mu o o d nu, nomp, o unfb nfomon Inu, nomp, o unfb nfomon mu b mod o od, uuy whn 3 dy How, onum pong gny my onu o po nfomon h fd u! Conum pong gn my no po oudd ng nfomon In mo, onum pong gny my no po ng nfomon h mo hn n y od, o bnkup h mo hn y od! A o you f md A onum pong gny my pod nfomon bou you ony o pop wh d nd - uuy o ond n ppon wh do, nu, mpoy, ndod, o oh bun Th FCRA pf ho wh d nd fo! You mu g you on fo po o b podd o mpoy A onum pong gny my no g ou nfomon bou you o you mpoy, o po mpoy, whou you wn on gn o h mpoy Wn on gny no qud n h ukng nduy Fo mo nfomon, go o wwwonumfnngo/nmo! You my m pnd off of d nd nun you g bd on nfomon n you d po Unod ''pnd" off fo d nd nun mu nud o-f phon numb you n f you hoo o mo you nm nd dd fom h h off bd on You my op ou wh h onwd d buu -8-XXX-XXXX! You my k dmg fom oo If onum pong gny, o n om, u of onum po o funh of nfomon o onum pong gny o h FCRA, you my b b o u n o fd ou! Idy hf m nd duy my ponn h ddon gh Fo mo nfomon, wwwonumfnngo/nmo Pg 4

13 S my nfo h FCRA, nd mny h h own onum pong w In om, you my h mo gh und w Fo mo nfomon, o you o o onum poon gny o you Aony Gn Fo nfomon bou you fd gh, o: TYPE OF BUSINESS: Bnk, ng oon, nd d unon wh o o $ bon nd h ff b Suh ff h no bnk, ng o, o d unon o houd, n ddon o h Buu: 2 To h x no nudd n m bo: Non bnk, fd ng oon, nd fd gn of fogn bnk b S mmb bnk, bnh nd gn of fogn bnk (oh hn fd bnh, fd gn, nd nud bnh of fogn bnk), omm ndng ompn ownd o ood by fogn bnk, nd ognzon opng und on 25 o 25A of h Fd R A Nonmmb Inud Bnk, Inud S Bnh of Fogn Bnk, nd nud ng oon d Fd Cd Unon 3 A 4 Cdo Subj o Suf Tnpoon Bod CONTACT: Buu of Conum Fnn Poon 7 G S NW Whngon, DC 2 b Fd Td Common: Conum Rpon C - FCRA Whngon, DC 258 (877) Off of h Compo of h Cuny Cuom An Goup 3 MKnny S, Su 345 Houon, TX b Fd R Conum Hp C PO Box 2 Mnnpo, MN 5548 FDIC Conum Rpon C Wnu S, Box # Kn Cy, MO 4 d Non Cd Unon Admnon Off of Conum Poon (OCP) Don of Conum Compn nd Ouh (DCCO) 775 Duk S Axnd, VA 2234 A Gn Coun fo Aon Enfom & Podng Dpm of Tnpoon 4 Sh S SW Whngon, DC 259 Off of Podng, Suf Tnpoon Bod Dpm of Tnpoon 925 K S NW Whngon, DC Cdo Subj o Pk nd Sokyd A N Pk nd Sokyd Admnon upo Sm Bun Inm Compn 7 Bok nd D 8 Fd Lnd Bnk, Fd Lnk Bnk Aoon, Fd Imd Cd Bnk, nd Poduon Cd Aoon 9 R, Fnn Compn, nd A Oh Cdo No Ld Abo Ao Dpuy Admno fo Cp A Ud S Sm Bun Admnon 49 Thd S, SW 8 h Foo Whngon, DC 24 Su nd Exhng Common F S NE Whngon, DC 2549 Fm Cd Admnon 5 Fm Cd D MLn, VA FTC Rgon Off fo gon n whh h do op o Fd Td Common: Conum Rpon C FCRA Whngon, DC 285 (877) Pg 5

14 (NEW YORK APPLICANTS ONLY) ARTICLE 23-A, NEW YORK STATE CORRECTION LAW 75 Dfon Fo h pupo of h, h foowng m h h h foowng mnng: () "Pub gny" mn h o ny o ubdon hof, o ny o o dpm, gny, bod o ommon (2) "P mpoy" mn ny pon, ompny, opoon, bo ognzon o oon whh mpoy n o mo pon (3) "D onhp" mn h h u of mn ondu fo whh h pon w ond h d bng on h fn o by o pfom on o mo of h du o ponb ny d o h n, oppouy, o job n quon (4) "Ln" mn ny f, n, pm o g of pmon qud by h w of h, po ubdon o num ondon fo h wfu p of ny oupon, mpoym, d, oon, bun, o pofon Podd, how, h "n" h no, fo h pupo of h, nud ny n o pm o own, po, y, o f ny xpo, po, hndgun, f, hogun, o oh fm (5) "Empoym" mn ny oupon, oon o mpoym, o ny fom of oon o duon nng Podd, how, h "mpoym" h no, fo h pupo of h, nud mmbhp n ny w nfom gny 75 Appby Th poon of h h ppy o ny ppon by ny pon fo n o mpoym ny pub o p mpoy, who h pouy bn ond of on o mo mn offn n h o n ny oh judon, nd o ny n o mpoym hd by ny pon who onon of on o mo mn offn n h o n ny oh judon pdd uh mpoym o gng of n, xp wh mndoy fofu, dby o b o mpoym mpod by w, nd h no bn mod by n xu pdon, f of f fom db o f of good ondu Nohng n h h b onud o ff ny gh n mpoy my h wh p o n on mpon n onnon wh n ppon fo mpoym md by pop mpoy o pouy md by u mpoy 752 Unf dmon gn pon pouy ond of on o mo mn offn pohbd No ppon fo ny n o mpoym, nd no mpoym o n hd by n nddu, o whh h poon of h ppb, h b dnd o d upon dy by on of h nddu' hng bn pouy ond of on o mo mn offn, o by on of fndng of k of "good mo h" whn uh fndng bd upon h f h h nddu h pouy bn ond of on o mo mn offn, un: Pg () h d onhp bwn on o mo of h pou mn offn nd h pf n o mpoym ough o hd by h nddu; o (2) h un o onuon of h n o h gng o onuon of h mpoym woud no n unonb k o popy o o h fy o wf of pf nddu o h gn pub 753 Fo o b ondd onnng pou mn onon; pumpon In mkng dmon puu o on n hundd ffy-wo of h hp, h pub gny o p mpoy h ond h foowng fo: () Th pub poy of h, xpd n h, o noug h nu nd mpoym of pon pouy ond of on o mo mn offn (b) Th pf du nd ponb ny d o h n o mpoym ough o hd by h pon () Th bng, f ny, h mn offn o offn fo whh h pon w pouy ond w h on h fn o by o pfom on o mo uh du o ponb (d) Th m whh h pd n h oun of h mn offn o offn () Th g of h pon h m of oun of h mn offn o offn (f) Th oun of h offn o offn (g) Any nfomon podud by h pon, o podud on h bhf, n gd o h hbon nd good ondu (h) Th gm of h pub gny o p mpoy n pong popy, nd h fy nd wf of pf nddu o h gn pub 2 In mkng dmon puu o on n hundd ffy-wo of h hp, h pub gny o p mpoy h o g ondon o f of f fom db o f of good ondu ud o h pp, whh f h pumpon of hbon n gd o h offn o offn pfd hn 754 Wn m upon dn of n o mpoym A h qu of ny pon pouy ond of on o mo mn offn who h bn dnd n o mpoym, pub gny o p mpoy h pod, whn hy dy of qu, wn m ng foh h on fo uh dn 755 Enfom In on o on by pub gn, h poon of h h b nfob by podng bough puu o y-gh of h p w nd u 2 In on o on by p mpoy, h poon of h h b nfob by h don of humn gh puu o h pow nd podu foh n ffn of h xu w, nd, onuy, by h Nw Yok y ommon on humn gh