Dear :

has been named to be a member of the Board of Directors at , a licensed-placing agency in the District of Columbia, located at . The above named person has recommended you as a reference.  Would you kindly fill out the form below to the best of your knowledge and return the form to this office as soon as possible.

Your Name:

Occupation:

Address:                                   ,                       City                                                                State                             Zip

Phone No.:

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 or supervision to children?  Yes   No

If Yes, please describe:

Have you ever employed or been employed by the applicant?   Yes   No

If Yes, in what capacity?

Would you recommend the applicant to care for children?  Yes   No

Why?

Return this form to: Department of Health Health Regulation Administration Child and Residential Care Facilities Division 825 North Capitol Street, NE Second Floor Washington, DC 20002 Phone: (202) 442-5929 Fax: (202) 442-4831 or (202) 442-9430

Attention:                    C&RCFD Staff Person