Reference Form

Please complete the form below if you have been asked to provide a reference for an Applicant.

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
Dates 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?