Employer Reference

Your Personal Information

We are considering the application of one of your employees for the adoption of a child. To enable
us to decide on this important step, it would help to have your impressions of the applicant as a prospective parent.

Information provided will be kept confidential and it is to be used solely for the purpose of evaluating the applicant. We will NOT use your personal information for any other purpose than to contact you about the reference form you have completed.

Name: *

Company:

Email Address:

Company address:

City:

State:

Zipcode:

Name of prospective adoptive parent:

Please outline your professional relationship with this person. How long has he/she worked with you and in what capacity?:

What are the responsibilities of the position held by the applicant? Briefly comment on the manner in which he/she assumes respo:

Briefly describe the quality of this person's relationship with colleagues, supervisors, supervisees and the public.:

What do you see as this person's strengths and limitations?:

Additional comments you may wish to make.:

Select the applicant's adoption counselor:

Do you give your approval for us to share your reference letter with another adoption agency, if the family requests that we do?: