Position Applied:______________________

Date of Contact *
Date of Contact
Address *
Address
Gender *
Classification *
Do you have pediatric experience? *
Do you have ventilator experience? *
Are you currently working? *
Current Availability *
Every Weekend
Every Other Weekend
Shift
Maximum Distance you are willing to travel *

 

CHHC REFERENCE CONTACT INFORMATION SHEET

Please provide the following information:  Failure to provide complete or accurate information can/will delay processing.

1.  Employment reference – Must be your current or last employer (Human Resources)

2.  Professional reference – Must be able to verify your pediatric experience (Former supervisor etc.)

3.  Character reference   – May be a co-worker, friend or non-relative.

Date *
Date
COMPANY NAME
NAME
NAME