APPLICANT’S INFORMATION

APPLICANT’S NAME

DATE OF APPLICATION

PREVIOUS EMPLOYER

ADDRESS OF FORMER EMPLOYER

TELEPHONE OF FORMER EMPLOYER

REASON I MAY RECEIVE BAD REFERENCE, IF ANY

OFFICE USE ONLY

EMPLOYEE INFORMATION

(APPLICANT DO NOT WRITE IN THESE SPACES)

START DATE
END DATE

POSITION AND DUTIES

REASON FOR LEAVING OR TERMINATION:

QUALITY OF WORK:

GOOD

FAIR

POOR

WORKS WELL WITH OTHERS:

GOOD

FAIR

POOR

JOB KNOWLEDGE/SKILLS:

GOOD

FAIR

POOR

ATTENDANCE/DEPENDABILITY:

GOOD

FAIR

POOR

COMMENTS (any other information you would like to share with us regarding this applicant?)

HOW VERIFIED:

PHONE

MAIL

FAX

INFORMATION PROVIDED BY:

TITLE

DATE

NAME OF REP. COLLECTING INFORMATION:

TITLE

DATE