Reference Request

Applicant: By completing the following information you hereby authorize the release of all information pertaining to current or previous employment and references/evaluations from those positions to American Medical Staffing.

"*" indicates required fields

Applicant: Please complete the following:

Your Name*

First Last

Certification*

Specialty*

Professional References

Please complete the following information for all supervisors within the last 2 years. Many facilities will only accept feedback from managers or directors (or the equivalent supervisor) so please make sure to include that information. It is encouraged to add as many supervisors (Charge RN, Team Leader, Lead Tech, etc.) as possible - the more references we have on file the stronger your profile will present. You must include your supervisors' work email and work phone number so that we can verify their position at the facility and feedback about your performance. Please do not include personal contact information unless you know they are no longer employed at the facility. In this case, we will verify their employment with the facility in an alternative manner. Upon submission, each reference will receive an e-mail and be asked to complete a confidential reference form that will be automatically transmitted to AMS on your behalf.

Reference 1

Name*

First Last

Position Title*

Facilty*

Unit*

Position Type*

Start Date Supervised*

End Date Supervised

Work Email*

Work Phone Number*

Cell Phone Number*

Reference 2

Name*

First Last

Position Title*

Facilty*

Unit*

Position Type*

Start Date Supervised*

End Date Supervised

Work Email*

Work Phone Number*

Cell Phone Number*

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Reference Request