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Reference Checkroom no.NH06 Rev. 08/15Reference check completed byTitleDateNote: If requested, provide a copy of the Authority to Release Information from the back of the State Application Form to

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A reference check - statescus is a form that must be completed by individuals providing references for a particular applicant or entity.

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Reference check - statescus typically requires the reference provider to give their contact information, relationship to the applicant, and feedback on the applicant's character and qualifications.

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