I,                                                                                                                 authorize my employers, school, law enforcement agencies, certifying agencies, licensing authorities and persons that may aid NURSEPARTNERS in determining my suitability for employment, to provide reference information to NURSEPARTNERS.  I hereby release all such employees, individuals, and/or organizations contacted from any liability for issuing this information to NURSEPARTNERS.  I also authorize NURSEPARTNERS to disclose this information to its customer(s) in the context of my assignment to its customer(s).

                                                                                                                              Applicant Signature

Dear Sir/Madam:

The above person has applied for employment in Health Care and has submitted you as a reference.  We would appreciate your reply and assure you that your answers will be held in the strictest confidence.

                                                                                                              NURSEPARTNERS  Representative