APP-08 – Personal Reference Form

HOME COMPANION SERVICES

APP-08 – Personal Reference Form - STEP-08
Home Companion Services
46 Route 25A, Suite 8 East Setauket, NY 11733
631-473-0700/1-800-473-4HCS(4427) Fax# 631-473-9507
Personal Referral

The applicant named below has applied for a position with our organization and has listed you as a personal reference. In order for us here at Home Companion Services to maintain our high standards, and because of the sensitive nature of our business, we ask you to evaluate this applicant’s personal integrity. We thank you for taking the time to return this to us, and assure you that the information provided will be held in strict confidence.
Thank you!
TO BE COMPLETED BY REFERENCE

Please Evaluate Circle Only One
Attendance:

ExcellentGoodAveragePoor
Punctuality:

ExcellentGoodAveragePoor
Reliability :

ExcellentGoodAveragePoor
Integrity:

ExcellentGoodAveragePoor
Empathy:

ExcellentGoodAveragePoor
What is your relationship to this applicant?
Signature of Applicant

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Date:

MonthDayYear
TO BE COMPLETED BY APPLICANT
Applicant Name:
Personal Reference’s Name: (No Relatives)
Reference Full Mailing Address:
Reference Email Address:
example@example.com
Years Known Relationship to Applicantblank I hereby authorize you to disclose all and any information concerning my employment to Home Companion Services. I understand this is in accordance with all applicable Federal and State Laws.
Date:

MonthDayYear
Applicant’s Signature:

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Should be Empty:

HOME COMPANION SERVICES

TO BE COMPLETED BY REFERENCE

TO BE COMPLETED BY APPLICANT