Employment Reference Form

* = Required Information

Name of Employer *

Position *

Address *

Department

Supervisor

Phone

The person whose signature appears beneath mine has applied to August Home Care Services, LLC. for employment and has submitted your name as a former employer for reference purposes. The serious nature of our responsibility to our clients is such that any consideration of the individual by August Home Care Services, LLC. is dependent upon receipt of satisfactory references. We would, therefore, appreciate your cooperation in replying to the questions below. Please be assured that your response will be kept in the strictest confidence. Thank you in advance for this courtesy.

I hereby authorize you to fulfill the above request for information.

Agency Representative *

Applicant's Name *

To be completed by previous company:

Position held in you employ *

Unit/Area Worked

Employment Dates: From *

Employment Dates: To *

Did applicant resign or was he/she terminated

Eligible for rehire?

Yes

Reason for Leaving

Comment

Name

Title

Date