Please correct the errors described below.

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.

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


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