Employment Reference Form

* Required Information

Name of Employer *

Position

Supervisor

Address

Phone

Email

The person whose signature appears beneath mine has applied to Kindhearted Healthcare Service Inc. for employment and has submitted your name as a former employer for reference purposes. The serious nature of our responsibility to our clients is such that any consideration of the individual by Kindhearted Healthcare Service Inc is dependent upon receipt of satisfactory references. We would, therefore, appreciate your cooperation in replying to the questions below. Please be assured that your response will be kept in the strictest confidence. Thank you in advance for this courtesy.

Agency Rep

I hereby authorize you to fulfill the above request for information.

Applicant's Signature

Clear

(Typed name constitutes legal signature)

Applicant's Name

Social Security #

Position held in your employ

Area worked

Employment dates - From

Employment dates - To

Did applicant resign or was he/she terminated?

Eligible for rehire?

Yes

Reason for leaving

Was this a travel assignment?

Yes

	VERY GOOD	SATISFACTORY	FAIR	POOR
Quality of work
Flexibility
Attitude
Emotional Stability
Adaptability to work under pressure
Dependability / Attendance / Punctuality
Cooperation / Ability to get along with others

Comments

Signature

Clear

(Typed name constitutes legal signature)

Title

Date

FOR OFFICE USE ONLY

Reference done by

Phone

Mail

Fax

Date

Initials

Name of Employer *

Position

Supervisor

Address

Phone

Email

Agency Rep

I hereby authorize you to fulfill the above request for information.

Applicant's Signature

Clear

(Typed name constitutes legal signature)

Applicant's Name

Social Security #

Position held in your employ

Area worked

Employment dates - From

Employment dates - To

Did applicant resign or was he/she terminated?

Eligible for rehire?

Yes

Reason for leaving

Was this a travel assignment?

Yes

	VERY GOOD	SATISFACTORY	FAIR	POOR
Quality of work
Flexibility
Attitude
Emotional Stability
Adaptability to work under pressure
Dependability / Attendance / Punctuality
Cooperation / Ability to get along with others

Comments

Signature

Clear

(Typed name constitutes legal signature)

Title

Date

FOR OFFICE USE ONLY

Reference done by

Phone

Mail

Fax

Date

Initials

Applicant Name

Position

Character Reference Name

Phone

1) Are you related to the applicant?

Yes

If yes, please explain

2) How many years have you known applicant?

3) In what context, have you known applicant (supervisor, colleague, friend, etc)?

4) Have you ever had to question the applicants reputation for:

a. Honesty

Yes

Don't know

b. Trustworthiness

Yes

Don't know

c. Diligence

Yes

Don't know

d. Reliability

Yes

Don't know

e. Good character

Yes

Don't know

f. Maturity

Yes

Don't know

Overall Recommendation

Highly recommended

Recommended, but with reservations

Recommended

Not recommended

Comments

FOR INTERNAL USE ONLY

Results

Date Checked

By Phone

By Mail

By Fax

Signature

(Typed name constitutes legal signature)

Date

I consent to the collection, use, storage, and processing of my personal and, where applicable, health-related information, including any data I submit on behalf of others, for the purpose of evaluating or fulfilling my request made through this form. I understand this will be handled in accordance with the Privacy Notice.