Professional Reference & Verification As part of our standard documentation and verification process, we are requesting the following information. PLEASE NOTE: By providing this information, you are granting Galileo Search, LLC permission to contact each individual listed to conduct professional reference verification and permission to verify your education, licensures and certifications. This information may be shared with one or more of our clients and with Top Echelon Contracting Inc. for the sole purpose of verifying / validating your employment history and professional credentials.Your Full Name (required)* Your Email (required)* Professional ReferencesPlease provide 3 (ideally 4) professional references, with at least 1 or 2 being previous supervisors.Reference Name Phone: Cell Phone PreferredPersonal Email Work Email Current Title Professional RelationshipPlease ChoosePeerImmediate Supervisor (reported to)A Superior (did not report to)Employee you ManagedName and location of facility where you worked together: How long did you work together? Reference Name Phone: Cell Phone PreferredPersonal Email Work Email Current Title Professional RelationshipPlease ChoosePeerImmediate Supervisor (reported to)A Superior (did not report to)Employee you ManagedName and location of facility where you worked together How long did you work together? Reference Name Phone: Cell Phone PreferredPersonal Email Work Email Current Title Professional RelationshipPlease ChoosePeerImmediate Supervisor (reported to)A Superior (did not report to)Employee you ManagedName and location of facility where you worked together How long did you work together? Reference Name Phone: Cell Phone PreferredPersonal Email Work Email Current Title Professional RelationshipPlease ChoosePeerImmediate Supervisor (reported to)A Superior (did not report to)Employee you ManagedName and location of facility where you worked together How long did you work together? Degree VerificationName, city & state of learning institution attended: Dates attended (MM/YYYY - MM/YYYY) Type of Degree Your full name at graduation from school - if different than above Date of Birth (required to confirm identity, with registration) Name, city, & state of learning institution attended Dates attended (MM/YYYY - MM/YYYY) Type of Degree Your full name at graduation from school - if different than above Name, city & state of learning institution attended Approximate dates attended (MM/YYYY - MM/YYYY) Type of Degree Your full name at graduation from school - if different than above Licensure Verification (RN, etc.)(include both "active" and "inactive" states)Your full name on licences - if different than above License Type Valid thru (mm/dd/yyyy) Your full name on licences - if different than above License Type Valid thru (mm/dd/yyyy) Your full name on licences - if different than above License Type Valid thru (mm/dd/yyyy) Current Certification(NOTE: If you have a CPHQ please include the CPHQ certification number.)Your full name on certificate- if different than above Certification name: Your full name on certificate- if different than above Certification name: Your full name on certificate- if different than above Certification name: Are You Legally Authorized To Work In The United States?(choose one below) Yes. I am legally authorized to work in the United States. No. I am not legally authorized to work in the United States. Permission to Market to Tobacco Free Employers(choose one below) Yes - You may present me, to those facilities that require Employees and outside Contractors, to successfully pass a tobacco/nicotine usage test, with non-positive results. No - I do not wish to be presented, to those facilities that require Employees and outside Contractors, to successfully pass a tobacco/nicotine usage test, with non-positive results. It is the policy and practice of Galileo Search, LLC to provide equal employment opportunity for all employees and candidates for employment without regard to age, sex, race, color, religion, national origin, disability, or sexual orientation, and to observe all applicable requirements of local, state and federal law.Additional InformationBy 'submitting' this information, I release Galileo Search, LLC. its employees and agents from all liability relating to your obtaining and use of such information and you’re providing such information to prospective employers. I authorize all companies, schools, organizations and other persons to provide such information to you and release them for all liability for doing so.
