Character Reference

Character Reference Form
This form is intended to collect a personal character reference for an individual
applying for a role in home care. Your honest and thoughtful feedback will help
ensure we select the most compassionate, responsible, and trustworthy caregivers.
Applicants' Details
Full Name of Applicant*

First NameLast Name
Referee Information
Full name of Referee*

First NameLast Name
Your occupation (optional)
What is your relationship to Applicant?*
Less than a year1-3 years3-5 years5+ years
Applicant's Character Reference
Please evaluate the applicant by selecting the rating that best describes your
experience with them.
SatisfactoryGoodExcellent
SatisfactoryGoodExcellent
SatisfactoryGoodExcellent
SatisfactoryGoodExcellent
SatisfactoryGoodExcellent
SatisfactoryGoodExcellent
SatisfactoryGoodExcellent
SatisfactoryGoodExcellent
Additional Comments (Optional)
Please share any additional observations or specific examples that reflect the applicant’s character and readiness for a home care position:
Signature (optional)

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Date

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Date
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Character Reference Form