PLEASE PRINT NAME AND ADDRESS
OF YOUR PREVIOUS EMPLOYER BELOW

Facility: name_of_employeer; ?>

Address: address_of_employer; ?>

City: State: Zip:

To:

Tel: ( tel_of_employer[1].$emp->tel_of_employer[2].$emp->tel_of_employer[3]; ?> ) tel_of_employer[6].$emp->tel_of_employer[7].$emp->tel_of_employer[8]; ?> - tel_of_employer[10].$emp->tel_of_employer[11].$emp->tel_of_employer[12].$emp->tel_of_employer[13]; ?>

Fax: ( ) -

Dear Employer:
The following applicant has applied for employment with WECURO, Inc. Kindly provide the requested
information to the best of your ability. The furnished reference information will be held in
strict confidence. Thank you for your cooperation.

Print Name fname,'')?> mid_name,'')?> lname,'')?> Social Security #: XXX - XXX - soc_sec[7],'')?> soc_sec[8],'')?> soc_sec[9],'')?> soc_sec[10],'')?>

Signature

FOR AGENCY USE ONLY

Employed From / / To / / Clinical Area

Kindly Check (if both check off both): HHA PCA

PLEASE EVALUATE:	OUTSTANDING	GOOD	FAIR	POOR
HHA Clinical skill
Ability To Work Independently
Cooperation
Attendence and reliability
Communication skills
Appearance

Has employee completed in-service requirements YES NO

ADDITIONAL COMMENTS:

IF NO LONGER EMPLOYED
IF NO LONGER EMPLOYED

WOULD YOU CONSIDER APPLICANT FOR REHIRE? YES NO
IF NOT, PLEASE EXPLAIN

SIGNATURE DATE / /

TITLE FACILITY