SCNC Reference Request

Page 1 of 1       Reference Request ~ St. Catherine's Nursing Center         331 South Seton Avenue Emmitsburg, MD 21727 TEL: 301-447-7006 FAX: 301-447-7015         I have applied to the above-mentioned facility for employment, and desire that they be fully advised of my employment record with your organization. I, therefore, respectfully request that you furnish the necessary information concerning my employment with your organization, and I hereby release you from any and all liability of damages for providing the information requested.       1. Attestation:*   Witness   Applicant   Date           Attention Applicant! Please DO NOT write below this line. For prospective & former employer use only.             2. Name         3. Social Security Number         4. Employment   Starting Date:   Ending Date:   Position:         5. Company Information   Company Name:   Company Street Address   Company City   Company State   Company Zip Code         6. Employee's Reason for Leaving         7. Please Complete: The information above is:   Correct   Incorrect   If incorrect, please note any discrepancies:               8. Evaluation:       Excellent   Good   Fair   Poor Ability         Attendance         Performance         Initiative         Cooperation         Personality               9. Has this applicant had any history of resident/patient abuse while employed with your organization:   Yes   No   If yes, please explain:               10. Would you re-employ?   Yes   No   If not, please give reason:               11. Completed by:   Name:   Title:   Date:           Please return this form to the above facility via fax or first class mail, ATTN: Human Resources Department. Please attach any additional comments.