1) TO EMPLOYER/FORMER EMPLOYER:

(Please fill in name of Employer or Former Employer)

DUE TO THE PRIVACY ACT, MOST EMPLOYERS ARE NO LONGER COMPLETING REFERENCE REQUESTS WITHOUT THE EXPLICIT PERMISSION OF THE INDIVIDUAL INVOLVED. THEREFORE, I AM GRANTING YOU PERMISSION TO SHARE WITH EASTSIDE NURSING & REHABILITATION CENTER, INC., INFORMATION CONCERNING MY PERFORMANCE AS A PRESENT/FORMER EMPLOYEE.

THANK YOU FOR YOUR COOPERATION IN THIS MATTER.

Signature

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2) TO EMPLOYER/FORMER EMPLOYER:

(Please fill in name of Employer or Former Employer)

DUE TO THE PRIVACY ACT, MOST EMPLOYERS ARE NO LONGER COMPLETING REFERENCE REQUESTS WITHOUT THE EXPLICIT PERMISSION OF THE INDIVIDUAL INVOLVED. THEREFORE, I AM GRANTING YOU PERMISSION TO SHARE WITH EASTSIDE NURSING & REHABILITATION CENTER, INC., INFORMATION CONCERNING MY PERFORMANCE AS A PRESENT/FORMER EMPLOYEE.

THANK YOU FOR YOUR COOPERATION IN THIS MATTER.

Signature

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3) TO EMPLOYER/FORMER EMPLOYER:

(Please fill in name of Employer or Former Employer)

DUE TO THE PRIVACY ACT, MOST EMPLOYERS ARE NO LONGER COMPLETING REFERENCE REQUESTS WITHOUT THE EXPLICIT PERMISSION OF THE INDIVIDUAL INVOLVED. THEREFORE, I AM GRANTING YOU PERMISSION TO SHARE WITH EASTSIDE NURSING & REHABILITATION CENTER, INC., INFORMATION CONCERNING MY PERFORMANCE AS A PRESENT/FORMER EMPLOYEE.

THANK YOU FOR YOUR COOPERATION IN THIS MATTER.

Signature

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Former Employer Release Form

We are fully accredited by the State of New York, and we maintain a reputation as one of the finest long-term care facilities in Western NY.