Reference Check Consent and Authorization Form

Please read the information on this form carefully and completely.

I have applied for employment with Crescent Home Care LLC. and have provided information about my previous employment. I authorize Crescent Home Care LLC to conduct a reference check with my present and/or previous employer(s). I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary, and employment history.

My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to Crescent Home Care LLC., whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Crescent Home Care LLC. from all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Crescent Home Care LLC.

This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.

Name: (please print)

Signature

Date

Cell Phone

Alternate Phone

We consider reference checks a valuable tool in the recruitment process to verify facts and obtain additional information about a potential candidate. Please complete all sections. Indicate N/A if the question is not applicable.

Applicant Name

Date of Reference Check

Person Checking Reference

Reference Name

Reference Organization

Relationship to Applicant

Supervisor

Peer

Other (Specify)

Dates of Employment

From

Salary: $

per

Position(s) Held

What was the nature of the applicant’s job?

Is this person eligible for rehire?

Yes

Additional comments

Printed Name/Title of Person Completing Form

Date

Signature of Person Completing Form