COPLINE
Stephanie Samuels, Creator and Founder
501 Iron Bridge Road #6
Freehold, NJ 07728
(732) 577-8300x8
1-(800) COPLINE
1-(800) 267-5463
Fax: (732) 577-9960
E-Mail: Copline@optonline.net
REFERRAL QUESTIONAIRE
On a separate piece of paper, please fill out the following questionnaire so you can potentially be added to a National database.
Respectfully,
Stephanie Samuels, Founder
1. Do you do any evaluations for hiring, firing, fit for duties or promotions and demotions for any department?
If so, please state whom. If it is throughout the State please say “Statewide”.
2. Does anyone in your practice do any evaluations for hiring, firing, fit for duties or promotions and demotions for any department?
If so, please state whom. If it is throughout the State please say “Statewide”.
If No:
a. Would you be willing to?
b. Why or why not?
PLEASE SEND A COPY OF YOUR RESUME OR CV, CURRENT LICENSE AND INSURANCE POLICY ALONG WITH THIS QUESTIONAIRE.