Reference Letter
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1Reference
Letter
Verification of Employment
Applicant’s Name_________________________________________SSN___________________Employment Dates ___________to___________
Travel
Per Diem
Core Staff
Name used at time of employment______________________________________________________
Role:
RN
LPN
ORT
ALLIED Please Indicate:_____________________
OTHER Please indicate:______________
Unit or Area worked________________________________ Reason for Leaving:
Resignation
Termination
Temporary Employee
Eligible for Rehire?
Yes
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
Applicant’s Signature________________________________________
consideration of the individual is dependent upon receipt of satisfactory
references. Therefore we would appreciate you cooperation in answering the
Date_______________________________________________________
questions below. Your responses will be kept in the strictest of confidence.
Thank you.
Please print clearly in black ink
Reference Given by:
Title
Facility
Unit/Area
Address
City
State
Zip
Phone
Fax
Signature
Title
Date
Verified Employment Dates Only
Evaluation: Please check the appropriate boxes below to best describe the applicant’s performance.
Very
Needs
Performance Evaluation
Excellent
Good
Satisfactory
Improvement
Poor
N/A
Clinical Competence
Willingness to Float
Accurately Documents
Follows Patient Care Plan
Follows Safety / Emergency Procedures
Patient / Family Communication Skills
Professional Attributes
Adaptability / Dependability
Attitude
Attendance
Cooperation / Teamwork
Interpersonal Skills
Leadership Ability
Comments: _________________________________________________________________________________________________
_________________________________________________________________________________________
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
Revised: 04/2009
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