Referral Form

Geri-Care Connection L.L.C. 158 Jelliff Mill Road New Canaan, CT  06840 PHONE: 203-972-7536 FAX:        203-966-5386   TO: DATE:   __________________________________________________________________is applying for the position of ____________________________________and has given us your name as a reference.  Your comments concerning the applicant will be appreciated and treated as confidential.   I hereby authorize Geri-Care Connection L.L.C. to inquire of any and all previous employers, public or government officials or agencies, law emforcement agencies or any other persons regarding my experience, reputation, character, ability, and qualifications.  I agree to hold all such persons and or Geri-Care Connection L.L.C., harmless with respect to any informaiton they may give, hereby releasing them from any liability to me arising there from. X______________________________________________       Signature of Applicant   X______________________________________________       Signature of Witness   _______________________________       Date   Punctuality______________________________________________________________________________________________________________   Honesty________________________________________________________________________________________________________________   Knowledge of Job________________________________________________________________________________________________________   Flexibility_______________________________________________________________________________________________________________   Dates of Employment_____________________________________________________________________________________________________   Would you Rehire?________________________________________________________________________________________________________   Signature___________________________________________________  Date______________________________