Application Reference Form

RE: Max Char: 40

The above named individual has applied for employment with our corporation. We would appreciate your sharing the
following information with us.

Your Name: Max Char: 40

Place of Employment: Max Char: 40

Date of Employment (From): Max Char: 10

Date of Employment (To): Max Char: 10

Hours of Service per week: Max Char: 10

Job Title: Max Char: 20

General Duties: Max Char: 200

Reason no longer employed: Max Char: 200

Please evaluate this person in the following areas:
Puncuality 40
Cooperation 40
Dependability 40
Flexibility 40
Decision-Making Ability 40
Technical Proficiency 40

Would you rehire this person? Max Char: 20

Any special Comments you would like to add? Max Char: 500

I hereby authorize CMS Health Care, Inc. and authorize and request each former employer and person, firm/corporation given as a reference to answer all questions that may be asked, and give all information that may be sought in connection with my application concerning me or my work, habits, character, skill or any action in transaction.

CMS Health Care, Inc. is an equal opportunity employer without regard to race, color, religion, sex, national origin, marital status or medical condition.