Dear :

Name of Facility:

has made an application to operate a Community Residential Facility. The person has recommended you as a reference.  Please fill out the form below and return it to this office within five days.

Sincerely,
Valerie A. Ware
Acting Program Manager

Personal Information
* Name:
* Occupation:
* Address:
* Phone:

Applicant Information
How long have you known the applicant?
Are you related?	Yes   No
Do you have any knowledge of the applicant's professional training or qualifications in providing care and/or supervision of adults?	Yes   No If Yes, please describe:
Have you ever been employed by the applicant?	Yes   No If Yes, in what capacity?
Would you recommend the applicant to care for residents who require a protective living arrangement?	Yes   No Why?