DepartmentofLabor,GuamEmploymentService

ApplicantReferral/Placement
FollowUpForm
Thisistointroduce
CoID:1393

(ApplicantsName)

Whoisbeingreferredtothepositionof:MedicalRecordsClerk
Referredby:TheresaC.Camacho
theresa.camacho@dol.guam.gov
Pleaseindicatetheresultsofthisreferralnolaterthanfive(5)workingdaysfromthedateof
receipt.Youcanfaxormailresultstotheaddressshownbelowassoonaspossible.Should
you have any concerns regarding this process, please feel free to contact the Employment
ProgramAdministrator,Ms.CatalinaCruzat4757028/4757137/4757010/4757004/475
7031.

================================================================
ThissectiontobefilledoutbytheEmployerindicatingtheresultsofthisreferral.
[]Individualwashiredandwillstarton:Date:________________Rate:____________
[]Individualwasinterviewedbutnotselected.(Indicatereasonfornonselection)
[]Individualdidnotqualify.(Indicatereasonfornonqualification)
Comments:_____________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
ReferralDate:
EmploymentRate@90Days:
October15,2012
Employer/CompanyName:
EmploymentRate@6Months:
DoctorsClinic
EmployerSignature/Title:Date:

EmploymentRate@12Months:

Final Closeout @ 18 Months: (EDW Notes/Comments):

P.O. Box 9970 Tamuning, Guam 96931-9970 Fax: (671) 475-7018 Tel: 475-7028 or 475-7019 Ste 400 GCIC Bldg,
Hagatna
GES 08-001
Revise 09/07/10

P.O. Box 9970 Tamuning, Guam 96931-9970 Fax: (671) 475-7018 Tel: 475-7028 or 475-7019 Ste 400 GCIC Bldg,
Hagatna
GES 08-001
Revise 09/07/10