Request For Employment Reference

Health Care Staffing LLC 300 Main Street North Easton MA, 02356 Tel: 508-2724390

Email: Info@omniprehealthcarestaffing.com Web: https://omniprehealthcarestaffing.com

The following applicant,,applied for a position with Omnipre Health Care Staffing and would appreciate you providing the information requested concerning possible employment.

The applicant consents to release of this reference information to Omnipre Health Care Staffing.

Applicant Signature

Date

The rest of this form is to be completed by a present or previous employer. This reference information will be treated in a confidential manner not to be released or shared with the applicant.

Name of Reference

Between what dates have you observed the work of the applicant? Beginning:

Beginning

Ending

What was your working relationship to the applicant?

Position held by applicant

Attendance/Promptness Record:_Good

-0-8

Poor

Please give reason applicant left or is leaving your employment

MeetsExceeds PerformancePerformance

How effective was applicant in the job?

PerformanceExpectationsExpectations

How reliable was applicant about meeting deadlines? How well did applicant establish rapport with other employees? How cooperative was applicant with other employees? How well does applicant demonstrate careful short-term and long-term planning? Communication skills:

- Oral - Written Applicant's knowledge of subject matter Ability to function effectively as a member of

Ability to take risks and effectively implement change Effective interaction with staff

Effective interaction with clients

Effective interaction with the community Ability to operate in a crisis situation

Would you employ/re-employ this applicant? How would you recommend this applicant? Enthusiastically not recommend To the best of your knowledge, has the applicant ever been accused of immorality or inappropriate Conduct? If yes, please explain:

To the best of your knowledge, has the applicant ever been accused of immorality or inappropriate Conduct? If yes, please explain

Additional comments you would like to make regarding the qualifications, strengths and or weakness of this applicant:

1. Strengths

2. Weakness

Signature of person completing this form

Date

Please print name

Title

Telephone number (where you can be reached to verify this reference)

Email address

example@example.com

Return this reference form by email or by fax to: Omnipre Health Care Staffing [Employer Address] [Employer Email] [Employer Fax]

MNIPRE

REQUEST FOR EMPLOYMENT REFERENCE FORM