Verification of Employment
Applicant’s Name_________________________________________SSN___________________Employment Dates ___________to___________
Name used at time of employment______________________________________________________
ALLIED Please Indicate:_____________________
OTHER Please indicate:______________
Unit or Area worked________________________________ Reason for Leaving:
Eligible for Rehire?
No If no, please explain______________________________________________________________
Notice to Employer
The applicant has applied to American Traveler and affiliates for employment
I hereby authorize the employer to furnish the requested information
to American Traveler Staffing Professionals and affiliates.
and has submitted your name as a former employer for reference purposes. Our
responsibility and commitment to our client hospitals is such that any
consideration of the individual is dependent upon receipt of satisfactory
references. Therefore we would appreciate you cooperation in answering the
questions below. Your responses will be kept in the strictest of confidence.
Please print clearly in black ink
Reference Given by:
Verified Employment Dates Only
Evaluation: Please check the appropriate boxes below to best describe the applicant’s performance.
Willingness to Float
Follows Patient Care Plan
Follows Safety / Emergency Procedures
Patient / Family Communication Skills
Adaptability / Dependability
Cooperation / Teamwork
For Corporate Use Only
Date/Time ___________________ Verified by ____________________ Signature _________________________________
1615 South Federal Highway Suite 300 Boca Raton, FL 33432
Toll Free Tel: 800.884.8788
Toll Free Fax: 888.884.6510