PERSONAL REFERENCE CHECK For:
(Reference Name)
(Reference Address)
(Reference Telephone #)
1 In what capacity have you known the applicant? For how long? 2 To your knowledge, has the applicant ever been convicted of a crime? if yes, please explain 3 Do you think this person is qualified to work in a facility/home or to care for children or developmentally disabled clients? Why? Why not? 4 Would you consider placing the responsibility for a child or developmentally disabled relative of yours with the applicant? 5 Additional Comments:
(Reference Signature)
Date
Please fill out the form for the person that you recommend to work with individuals with disabilites.
Please sign and have notarized.
Contact your local sheriff’s office to obtain a “local law checkâ€
Name:
Email:
