Please complete the reference information below.

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* 1. Name of Applicant for whom you are providing a reference.

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* 2. Please provide your name and title.

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* 3. Please provide your telephone number and email address in case any follow-up is needed.

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* 4. How do you know the Applicant (what is your professional relationship)?

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* 5. How long have you known this Applicant?

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* 6. Position they held during this time:

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* 7. Dates of employment:

Please rate the following items on a scale of 5-1, with 5 being the highest and 1 being the lowest.

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* 8. Quality of work:

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* 9. Efficiency at work:

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* 10. Cooperation and attitude:

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* 11. Initiative and responsibility:

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* 12. Did they have any issues with attendance or tardiness?

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* 13. Did you have any concerns with their professional appearance?

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* 14. What were their greatest strengths?

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* 15. What were their biggest opportunities for improvement?

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* 16. What was their reason for leaving this position?

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* 17. Is this Applicant eligible for rehire?

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* 18. Would you recommend them for hire?

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* 19. Please list any other comments you'd like to add.

Thank you for taking the time to complete this reference request!  You are welcome to contact us directly with any questions or problems at (920) 320-4031 or recruiter@hfmhealth.org.

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