02. NEW VERSION Conf. Reference Request and Verification

Confidential Reference Request and Verification -1-

Reference 1 Name

Date

Reference Company / Address

Reference 1 Phone

Format: (000) 000-0000.

Fax

Reference relationship / Title

Email

example@example.com

I, (Name of applicant) Care LLC for employment and have had a face-to-face interview with a Galaxy Home Care representative. I

I Name of applicant

hereby release from all liability the company and/or person completing this form and authorize them to release all information regarding my employment with them.

Employed from date:

Employed to date:

Position Held

Applicants Signature*

Galaxy Home Care conducts a complete reference check, prior to hiring, on each applicant for employment. All information you supply is confidential. Any statements you wish to make that would help us determine a placement for this applicant may be entered in the space provided for "Comments" or you may call the office for a confidential conversation. We appreciate your prompt reply.

Is the above information, correct?

Please rate the applicant using the following guidelines: Above average Attendance/Dependability Quality of Work Follows Directions Cooperation/Attitude

101 Coventry CircleLansdale, PA 19446Fax: (215) 365-0733 Phone (215) 588-5068

Confidential Reference Request and Verification -2-

Reference 2 Name

Date

Reference 2 Company / Address

Reference 2 Phone