The person whose signature appears beneath mine has applied to Grace and Mercy Health Services for employment and
has submitted your name as a personal reference. 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.
I hereby authorize you to fulfill the above request for information.
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