PROFESSIONAL REFERENCE

Date       __________         Reference’s Name ____________________________             Title        _________________________

Facility Name       _________________________________________                                Phone     _________________________

Facility Address   _________________________________________                                City        _________________________     

State       __________         Zip Code               _________________________                     FAX        _________________________

PERFORMANCE EVALUATION

What was the applicant’s position during his/her employment with you? __________________

Applicant’s dates of employment: From_____/_____/______ To_____/_____/______Would you rehire applicant? ______

Reason this applicant left your employ: __________________________________________________

Above                                    Below

Excellent         Average           Average           Average           Poor

Quality of Work                           O                     O                     O                     O                  O

Productivity                                 O                     O                     O                     O                  O

Professionalism                            O                     O                     O                     O                  O

Emotional Stability                       O                     O                     O                     O                  O

Flexibility                                     O                     O                     O                     O                  O

Dependability                              O                     O                     O                     O                  O

Enthusiasm Toward Job               O                     O                     O                     O                  O

Leadership/Management Ability   O                     O                     O                     O                  O

Communication Skills                  O                     O                     O                     O                  O

Attendance/Punctuality                O                     O                     O                     O                  O

Appearance                                O                     O                     O                     O                  O

Interpersonal Skills                      O                     O                     O                     O                  O

COMMENTS: (Please provide a professional profile of the applicant in three or four sentences.)

_____________________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

Reference’s Signature ___________________________      Title____________     Date________________