All Fields Required

has made an application to operate a Child-Placing Agency in the District of Columbia. The 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?

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?	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 work with children who require a nurturing living arrangement?	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