Personal Reference

Personal Reference
Your name has been given as a personal reference for an applicant to North Country Home Services for a Home Care Worker positon. The job requires a mature, responsible individual who can work well withlittle direct supervision. A Home Care Worker works with the disabled, sick and elderly to provide care and support in the client’s home environment.

Please answer the following to the best of your ability:
Name of Applicant:*
Relationship to Applicant:
How long have you known the individual?
Do you feel this person would make a good Home Care Worker?

YesNo
Please explain:
Do you feel this person has any particular strengths or weaknesses we should know that might affect the way they would perform in this job?
If you needed to hire someone to provide care or support for you or a family member, would you want this person providing that care/support?

YesNo
Please provide your name, address and telephone number in the event we need further information. Thank you.
Name

First NameLast Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
References must be on file before this applicant can be employed. Please complete this reference as soon as possible so that we may consider this applicant.

Thank you for your time and effort.
North Country Home Services

Reviewed by NCHS RN: ___________________________________________
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