Submit Reference Form

To complete the employment process, we may need to speak to at least three professional references (preferably former employers/supervisors) and confirm your educational history along with your professional credentials.

Please complete and submit this form to Global HealthCare Recruiters at your earliest convenience. Thank you!

Your Contact Information

Name *

First

Last

Phone *

Personal Email Address *

First Reference

Name *

Title *

Professional relationship to you *

Facility *

Name of Facility

Facility Location *

City/state of facility

Phone *

Email *

Second Reference

Name *

Title *

Professional relationship to you *

Facility *

Name of Facility

Facility Location *

City/state of facility

Phone *

Email *

Third Reference

Name *

Title *

Professional relationship to you *

Facility *

Name of Facility

Facility Location *

City/state of facility

Phone *

Email *

About You

Active Credentials

AHIMA, AAPC, and/or any additional active credential(s) and all associated ID number(s)

Educational Background

Please list all colleges, city, state and degree received

Have you ever worked under a different name?

Are you legally eligible for employment in the United States?

By submitting this form, I expressly authorize, without reservation, GlobalHealthCare Recruiters to contact and obtain information from all listed references, licensing authorities, professional associations and educational institutions and to otherwise verify the accuracy of all information provided by me in this form, on the resume provided and/or during the interview process. I hereby waive any and all rights and claims I may have regarding Global HealthCare Recruiters for seeking, gathering and sharing such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

DOB and Social Security number are required to confirm most college degrees, this information may be requested at a later date.

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