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 formReference Phone #If there are additional questions, we may contact you at this numberReference Title*Professional title of the person filling out this form. Example: Director of Rehab, Charge Nurse, Department Head, etc.FacilityThe facility in which the reference and applicant worked togetherDate of EmploymentMonth/Year start and end of end of Applicants's employment at the facility stated aboveWhat 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 positionHow 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?