Employee Referral Form

Date Form Initiated

Date

Name of Employee Making the Referral

First NameLast Name

Referring Employee's Position Held

Referring Employee's Email Address

example@example.com

Name of the Applicant Being Referred

First NameLast Name

Referred Position

Referred Department

Applicant's Email Address

example@example.com

Applicant's Phone Number

Area CodePhone Number

Qualifying Position

If other position, please list the job title below.

By submitting this form, I acknowledge that I've instructed the applicant to ensure that my name is on their application. I understand that if my name is not listed as a referring employee that I will not be eligible to receive the Employee Referral Bonus. I understand that not all positions are eligible for a referral bonus and this changes due to business need. I attest that I have read and understand the Employee Referral Bonus policy, as well as the guidelines below.

REFERRAL BONUS PAYMENT:

A. A payment of one half of the bonus is issued after the new hire completes 90 days of employment.

B. A payment of the final one half of the award is issued after the new hire completes one year of employment.

C. Referral bonuses are not paid for referral of candidates who have previously completed an application for employment within the past six months or who are already employed by URMC, retirees, or working with URMC on a contract basis.

D. To be eligible for either of the two referral bonus payments described herein, the referring employee must be actively on the payroll at the time of payment.

E. To avoid any possible conflicts of interest, referral bonuses are not paid for candidates referred by Senior Management or the Human Resources department. Department Directors are eligible for the Medical Center referral bonus if the referral/hire is made to a department other than their own department for which they have hiring responsibility.

F. Upson Regional Medical Center reserves the right to deny bonus payments to any employee who improperly makes promises or assurances of employment to prospective or actual candidates, or otherwise engages in improper or inappropriate conduct related to this program. Upson Regional Medical Center reserves the right to review and amend the program or may discontinue the program at anytime..