Allied Health Professionals Credentialling

EMPLOYMENT REFERENCE REQUEST

The applicant named below is being considered for appointment to Columbia University Medical Center. To help us evaluate this candidate, please complete the form and return to us as soon as possible. All information will be handled in a confidential manner. Thank you for your cooperation and assistance.

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To Be Completed by Applicant

Applicant's Name (Print or type):_________________________ S.S.#:_________________

Past Employer:_______________________________________Phone#:_________________

Address:_______________________City:__________________State:_____Zip:__________

Waiver/Release:

I authorize Columbia University Medical Center or any agent it expressly authorizes to act on its behalf, to investigate fully all the information and references contained on my application. I release my current and former employers from any liability and responsibility for providing written or verbal information about me to Columbia University Medical Center.

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Applicant's Signature                                        Date

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To Be Completed by Former or Present Employer

Position Held:_______________________Date Hired:___________ Date Terminated:__________

Reason for Leaving________________________________Would you Re-Employ?_____

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Signature/Title of Person Completing                                        Date

Send completed form to:            

Columbia University
Office of Human Resources
630 West 168^th St., Box 29
New York, NY   10032

Tel# 212-305-3819
FAX# 212-305-5728