Form Soc 865 - In-Home Supportive Services (Ihss) Request For Applicant Provider Reference Page 2

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REFERENCE REQUEST FOR:
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3.
Please give your opinion of this person’s character.
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4.
Please describe any interaction you have observed between this person and elderly, blind, or disabled
individuals.
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5.
Please add any comments you feel are relevant about this person and his/her ability to work as an IHSS
provider.
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Name Of Person Submitting Reference: (Please Print) Your Signature:
Date:
SOC 865 (7/12)

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