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Applicant Name :   
Discipline :   
Facility :   
Dates of Employment :   
Contact Name (Supervisor) and title :   
Contact Telephone Number :   
I hereby give my consent to release any and all of my employment records to HEALTH SOURCE GROUP that may be relevant to my work history with regard to references and past performance history. This information may be given verbally or in writing with my full permission.  
Print Name :   
Signature :   

Kindly complete this form with regard to the above applicant’s work history and return to Health Source Group via fax to 516-605-1306. Please call us with any questions or concerns at 516-605-1310 ext 204. 

The above mentioned applicant was employed from

Please rate this applicant’s past performance history while in your employ
Applied Clinical Skills:
Verbal Skills:
Work Relationships:
Ability to work independently:
Would you rehire this individual?

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