The person whose signature appears below has applied to Professional Nursing Service, a division of Bonneville Health Recruiters, for employment and has submitted your name as a former employer for reference purposes. Any considerations of this individual by Professional Nursing Service are dependent upon receipt of satisfactory references. We would, therefore, appreciate your cooperation in replying to the questions listed below. Please be assured that your response will be kept in the strictest confidence. Thank you in advance for your time and efforts.
and boxes with yellow shading are REQUIRED fields.
Social Security #:
I hereby authorize you (previous employer) to respond to the above request for information.
I hereby authorize you (previous employer) to respond to the above request for information. Date:
(This section to be filled out by previous employer)
Type/Size or Unit:
Applicant Was a Temporary Employee
Is applicant eligible for rehire?
If not, reason:
Quality of Work
Quantity of Work
Attendance & Punctuality
Signature (print name):
Agency Signature (print name):