RE: Recommendation For _________________________

Position Applying For _________________________

The above named Applicant has indicated that he/she was previously employed by you or has given your name as a personal reference. Your evaluation of him/her will be sincerely appreciated, and will be held completely in confidence.

Thank you for your assistance in completing the reference request.

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I hereby authorize Osceola Medical Center to contact the employers and personal references listed on my application to ascertain any and all information pertaining to my capability to perform available employment and hereby release such employers and references from any and all liability. This will also include a criminal background check.

Date: __________ Signature of Applicant: __________________________

CONFIDENTIAL REFERENCE REQUEST

Employment Reference:
Date of Employment: _______ to _______
Position and/or Title: ______________________________
Reason For Leaving:
______________________________________________________________
Resigned
_____
Resignation Requested
_____
Discharged
_____
Laid Off
_____
Would you Rehire?
_____ _____
Yes       No
No If no, why?____________________________________________


Quality of work:
_____         _____            _____
Good          Adequate       Poor

Productive output:
_____         _____            _____
Good          Adequate       Poor

Attendance:
_____         _____            _____
Good          Adequate       Poor

Cooperation:
_____         _____            _____
Good          Adequate       Poor

Initiative:
_____         _____            _____
Good          Adequate       Poor

Personal Reference:
How long have you known applicant: ____________________
Other Comments: (use back of page for additional space)

Date:__________ Signature:____________________
Title:____________________

Upon completion of the reference form, please return it to Human Resources for further processing.

Human Resources Department
Osceola Medical Center
301 River Street -- P.O. Box 218
Osceola, WI 54020