Dear Sir/Madam:

You have been identified as a reference for the individual named below. We would appreciate your supplying the following information at your earliest convenience. Thank you for your prompt reply.

Recruiter
Human Resources
FAX: (361) 808-2115

I hereby authorize any prior employers, educational institutions and/or enforcement agencies to provide to the authorities of the Driscoll Children’s Hospital such information, transcripts, records or official copies, etc. as may be deemed necessary.

APPLICANT’S SIGNATURE: __________________________ DATE: _________________________________
(Applicant please sign and date only)

APPLICANT: ____________________________________SS# _______________________________________

LAST NAME WORKED UNDER: ___________________ TERM DATE: _______________________________

EMPLOYMENT DATES: FROM ____________________ TO: _______________________________________

FULL TIME _____ PART TIME ______POOL ______ TITLE: ________________________________________

ELIGIBLE FOR REHIRE: YES ____ NO ____ IF NO, PLEASE COMMENT: ___________________________

__________________________________________________________________________________________

REASON FOR LEAVING: ____________________________________________________________________

ADDITIONAL COMMENTS: ___________________________________________________________________