Reference Check Form


Posted on May 4, 2012 by admin | in Background Check

REFERENCE CHECK FORM



REFERENCE INFORMATION BEING REQUESTED ON:

Applicant’s Name:
First Middle Last

REQUESTING AGENCY INFORMATION: (To be completed by the hiring department)

Date of Request:  
Name of Hiring Department:  
Department Address:  
 
Representative’s Name:  
Representative’s Title:  
Representative’s Phone:  

EMPLOYER INFORMATION:
(To be completed by previous/current employer if by mail; or by hiring department if by phone)

This reference information furnished by: Phone

Mail 		Number:
Address:
Date Completed:  
Name of Employer:  
Representative’s Name:  
Representative’s Title:  
Representative’s Phone:  

If requested by Mail, please return to the Hiring Department’s address listed above.

APPLICANT INFORMATION:

Applicant’s Name:
First Middle Last
Employment Dates:
From: To:

Reason for Leaving:  
Major Job Duties:  
Special Skills:  
 

Met job requirements in terms of quantity of work? Exceeded Requirements
Met Requirements
Did Not Meet Requirements
Met job requirements in terms of quality of work? Exceeded Requirements
Met Requirements
Did Not Meet Requirements
Cooperated with fellow employees and supervisors? Yes No
Usually came to work on time? Yes No
Absent more than 10 days (except vacation) in the last year of employment? Yes No
If Yes, please explain:
Received an oral or written warning for performance or committed any misconduct while on the job? Yes No
If Yes, please explain:
Received an oral or written warning for performance or committed any misconduct while on the job? Yes No
If Yes, please explain:
Required close supervision? Yes No
If Yes, please explain:
Would you rehire (or retain) this person? Yes No
If No, why?
Additional Comments/Explanations:

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