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Ohio Senior Medicare Patrol (SMP) Reference Form

    SMP Volunteer Applicant's Name (required)

    Your Name (required)

    Your Email (required)

    Your Phone Number(required)

    Whare are the Applicant's biggest strenghts?

    Are there any areas where the Applicant could improve?

    Has the Applicant ever shown any characteristics or traits that might cause problems in this position?

    Has the Applicant ever done anything that prevents you from recommending him to work in confidence with older adults?

    Is the Applicant on-time and dependable?

    Is there anything else we should know about the Applicant?

    Click on the button below to submit your reference to Pro Seniors.

    By signing below you are affirming that the information in this report is true and accurate to the best of your knowledge.

    (Please sign by drawing your signature with your computer mouse or finger on your phone or tablet)