Applicant’s Name:

Date:

Position Applied For:

Dept.:

Person Conducting Check:

Title:

Previous Employer:

Person Giving Reference:

Title:

Verified Dates of Employment: From To

Position Title: Begin End

End

Salary/Wages: Begin End

End

Brief description of previous job duties:

How would you describe applicant’s performance of job duties?

What value did the applicant add to their company?

How did the applicant get along with others?

Reason for applicant’s termination:

Is applicant eligible for rehire with this company?YesNo

Yes

No

If not eligible for rehire, why not?

Additional Notes: