EMPLOYMENT REFERENCE FORM

Name of Employer

Position:

Address:

Department:

Supervisor:

Phone:

The person whose signature appears beneath mine has applied to Grace and Mercy Health Services 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 Grace and Mercy Health Services 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.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Grace and Mercy Health Service

Applicant’s Signature

Applicant’s Name:

Social Security #:

Position held in your employ:

Unit/Area worked:

Employment dates: From:

To:

Did applicant resign or was he/she terminated

Eligible for rehire?

Yes No

Reason for leaving

Was this a travel assignment?

Yes No

PERSONAL EVALUATION:

Quality of work