Form Tlr 301e - Reference Request
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REFERENCE REQUEST FOR: _______________________________________
You must enter your full name before you give this form to your reference for completion.
The above named person has submitted an application for the TrustLine Registry. This person has selected you to write a
reference statement on his/her behalf.
If you are related to this person in any way, please do not complete this reference statement.
Please complete the entire form. Your honest reply will help us ensure high quality, license-exempt child care.
YOUR NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
DAYTIME PHONE NUMBER
(
)
1. How long have you known this person?
2. How do you know this person?
3. Please give your opinion of this person’s character.
TLR 301E (3/11)
PAGE 1 OF 2
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