Leora Home Health - Employee Referral Form

Your Information

Your Full Name *

Your Employee ID *

Found on your employee badge or payroll stub

Your Email *

Candidate Information

Candidate's Full Name *

Candidate's Email *

Candidate's Phone Number *

Format: 512-555-0100

Position Referring For *

Referral Bonuses:

CNA: $750 total ($250 at hire, $250 at 90 days, $250 at 180 days)
LVN: $1,000 total ($300/$350/$350)
RN: $1,500 total ($500/$500/$500)
Specialized: $2,000 total ($600/$700/$700)

Additional Details

How do you know this candidate? *

Why would they be a great fit for Leora? *

2-5 sentences about their strengths and why they align with our values

Does the candidate have required certifications/licenses?

Additional Notes or Special Skills

I confirm that I have discussed this opportunity with the candidate and they are aware I'm submitting this referral. I understand the candidate must mention my name in their application to qualify for the referral bonus. *

I confirm that I meet the eligibility requirements (employed for 60+ days, in good standing) and understand the bonus payment structure. *