Reference Check Form

Date

To

From

Fax #

Phone #

Fax #

Dear Sir/Madame:

Your organization has been named as a reference for the below named individual. Please complete the information below indicated with an * and return to the fax number above. Thank you for your time.

APPLICANT INFORMATION:

I , request

to release information below in providing reference to Infiniti Home.

Signature of Applicant

Dates of Employment provided by applicant

Organization Phone #

* Name of Person providing reference

* Dates of Employment Verified

Yes

No

* Dates were

* Employee is Eligible for Re-hire

Yes

No

What is the reason?

* Employee Work History

It is against organizational policy to release this information

TRAIT

Punctual

Yes

No

Positive Attitude

Yes

No

Positive Work Relationship

Yes

No

For telephone references

Signature of Infiniti staff taking reference

Date

Facsimile Confidentiality Information

NOTICE TO RECIPIENT

As a recipient of this information, you are prohibited to further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by State Law, Federal Regulation or HIPPA Privacy Standards.

IMPORTANT CONFIDENTIALITY NOTICE!!!

THE INFORMATION CONTAINED IN THIS FACSIMILE MESSAGE IS CONFIDENTIAL AND INTENDED SOLELY FOR THE USE OF THE INDIVIDUAL OR ENTITY NAMED ABOVE. IF THE READER IS NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE OR AGENT RESPONSIBLE FOR DELIVERING IT TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION, COPYING OR UNAUTHORIZED USE OF THIS COMMUNICATION IS STRICTLY PROHIBITED. IF YOU HAVE RECEIVED THIS FACSIMILE TRANSMISSION IN ERROR, IT SHOULD BE RETURNED TO THE SENDER AS SOON AS POSSIBLE.