References - Assist Medical Staffing

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Professional Reference Request

Please complete this professional reference form. This information will help Assist Medical Staffing hire staff with qualifications that meet our professional standards. Thank you for your assistance.

Your Name *

First

Last

Your Job Title *

Reference Information One:

Supervisor Name *

Supervisor Phone *

Facility Name (facility you worked at) *

Facility City *

Facility State *

Date Employed From *

Date Employed To *

Are you eligible for re-hire?

Yes
No

Communication Skills

Excellent
Above Average
Below Average
Poor

Quality of Work

Excellent
Above Average
Below Average
Poor

Reliability

Excellent
Above Average
Below Average
Poor

Attitude

Excellent
Above Average
Below Average
Poor

Professionalism

Excellent
Above Average
Below Average
Poor

Reference Information TWO: