Professional References

After filling out your application and skills checklists, we give you access to an interactive professional reference request form. This helps us to match you more quickly to the assignments you want, and gives you a leg up over others interested in the same assignments, which often fill quickly. Please complete and submit up to three of your most recent supervisors and/or managers.

Completing Your References:

Please complete this reference request by completing all required fields. A valid e-mail address for your reference contact is required. This form will be submitted to the contact's email address which you have provided. Please note that acceptable reference contacts include present or former supervisors, managers, team leads, charge personnel or other titles of individuals who currently supervise or previously supervised you in a work setting. Peer references are not applicable.

Your Profile
Please enter your full legal name as it appears on your Social Security Card.
* First name: * Last name: Middle name:
Other First Name used: Other Last Name used:
* Email address:
* Last 4 of social security number:
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You can submit up to 3 reference requests. To add another reference request, click on "Add Another". To submit your reference request(s), please click "submit" at the bottom of the page.
Reference No. 1
* Evaluator First name: * Evaluator Last name:
Evaluator Email address: Evaluator Phone #:


*You must enter either an email address and/or a telephone number.
* Evaluator Position Title: If Other, Please List:
Facility Profile
* Facility name: * Facility type:
* Facility city: * Facility state: Zip code:
Unit Profile
* Unit/floor/dept name:
* Discipline: * Specialty:
* Number of beds in unit:
If not applicable, please enter n/a
* Average patient caseload:
1 : If not applicable, please select n/a
* Unit description:
May include common patient diagnoses, patient acuity, special equipment used, special skills/competencies, etc.
* Your position held:
Dates employed: (To date not required if currently working)
* From: To:
(mm/dd/yyyy) (mm/dd/yyyy)
* Charge experience?:
Attestation
 
I attest that the information I have given is true and accurate to the best of my knowledge and that I am the individual completing this form. I hereby authorize the Evaluator to release employment information relative to this experience to AMN Healthcare. I understand this reference will be subject to verification by AMN Healthcare.
* *Date: