Reference Form

Applicant's Name*

The Name of the person applying to the position about whom you are providing reference information/feedback.
Today's Date*
Reference Name*

The name of the applicant's reference/person filling out this form
Reference Phone #

If there are additional questions, we may contact you at this number
Reference Title*

Professional title of the person filling out this form. Example: Director of Rehab, Charge Nurse, Department Head, etc.
Facility

The facility in which the reference and applicant worked together
Date of Employment

Month/Year start and end of end of Applicants's employment at the facility stated above
What was the Applicant's position?*

The position held by the Applicant at the facility listed above.
How was their overall performance?*
Applicant's performance in their position
How was their ability to get along with others?*
What is their greatest strength?*
Was the applicant punctual? Timely with documentation?*
Are they eligible for rehire?*
Any additional comments about the applicant?