Reference Letter

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.

Red text and boxes with yellow shading are REQUIRED fields.


Applicant Information:
 First Name:        Middle Initial:
 Last Name:       
 Social Security #:       
 Previous Employer:       
Current Address:
City:
State:        ZIP:
Phone:
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)

Employee Evaluation:
Employment Dates: From: To:
Position Held:
Type/Size or Unit:
Check One: Applicant Resigned
Applicant Terminated
Applicant Was a Temporary Employee
Is applicant eligible for rehire? Yes     No
If not, reason:
Performance Evaluation: Excellent Above Avg. Average Below Avg. Not Observed
Quality of Work
Quantity of Work
Flexibility/Adaptability
Dependability/Reliability
Interpersonal Relations
Clinical Skills
Attendance & Punctuality
Personal Appearance
Comments:
Signature (print name):     Title:     Date:
Agency Signature (print name):     Title:     Date: