Reference Check Form

ATTN

Date

ORGANIZATION

ADDRESS

PHONE NUMBER

FAX

The applicant listed below is applying for a position as,

Enter position here

and has provided your name as an employment reference. As we place great importance on the thorough screening of our applicants, we would appreciate a prompt and thoughtful response.

Thank you in advance

SECTION 1 – To be completed by the applicant

owner of the Social Security #,

hereby authorize FLORIDA CONCIERGE HOME CARE to contact you as my previous employer.

APPLICANT’S SIGNATURE

SECTION 2 – To be completed by the previous employer

1. Length of employment from

2. Functioned in the capacity of RN

LVN/LPN

HHA/CNA

3. Reason for leaving

4. Is the applicant eligible for rehire?

Yes

PLEASE COMMENT ON THE APPLICANT’S ATTRIBUTES USING THE FOLLOWING SCALE:

POOR (P), FAIR (F), GOOD (G), VERY GOOD (VG), EXCELLENT (E)

Ability to follow instructions

Reliability and Attendance

Professional dress and grooming

Ability to work with others

Willingness to assume responsibility

Quality of work

Skills / Proficiency

Job Knowledge

Overall Job Performance

Additional Comments

Name (please print)

Signature

Position/Title

Date

Thank you!

WHEN COMPLETED PLEASE EMAIL TO: Joe@flconciergehomecare.com

Phone

This field is for validation purposes and should be left unchanged.

561-678-0111