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Reference Check Form

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MM slash DD slash YYYY
The applicant listed below is applying for a position as,
and has provided your name as an employment reference. As we place great importance on the thorough screening of our applicants, we would appreciate a prompt and thoughtful response.

Thank you in advance

SECTION 1 – To be completed by the applicant

hereby authorize FLORIDA CONCIERGE HOME CARE to contact you as my previous employer.
Clear Signature

SECTION 2 – To be completed by the previous employer

MM slash DD slash YYYY
MM slash DD slash YYYY
4. Is the applicant eligible for rehire?
PLEASE COMMENT ON THE APPLICANT’S ATTRIBUTES USING THE FOLLOWING SCALE:

POOR (P), FAIR (F), GOOD (G), VERY GOOD (VG), EXCELLENT (E)
Clear Signature
MM slash DD slash YYYY
Thank you!

WHEN COMPLETED PLEASE EMAIL TO: Joe@flconciergehomecare.com

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Check Your Eligibility in Minutes

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Caring for Someone with Dementia or Alzheimer’s?

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