Reference Check Form

* Required Information

Full Name *

SS Number *

Position Held *

Dates of Employment

From *

To *

Present/Former Employer/Individual Name *

Full address of Employer *

Employer Phone *

Fax Number

By signing below, I authorize American Primary Healthcare, Human Resources Department to contact my current and former employer(s) to obtain references and other information about my employment, including but not limited to: Attendance, Performance, Reason for separation, Dates of employment, Position held, Eligibility for rehire, and final salary.

I also authorize my current and former employers to respond to such requests for information and I release all persons from any and all claims and liability which may arise from the release of such information.

Draw It

Date *

ASSESSMENT OF WORK ETHIC

Quality of Work *

Excellent

Good

Poor

Reliability *

Excellent

Good

Poor

Conduct Performance *

Excellent

Good

Poor

Ability to work with others *

Excellent

Good

Poor

Eligible for Rehire *

Yes

No

Please Explain

Dates of Employment:

From *

To *

Telephone Inquire, Spoke with *

Reference Check Completed by *

Email Address *

Date *

Received Date *