EMPLOYEE REFERENCE REQUEST

I, [employee], hereby authorize [former employer] to release any and all references and records related to my past employment and work history to [prospective employer]. I release and forever discharge the above named former employer and prospective employer of any and all claims related to this Employee Reference Request and any related exchange of records or other communications related to my past employment.

DateSocial Security Number

SignaturePrinted Name

Please answer the following questions as thoroughly as possible regarding the above named individual and their employment with your company. Thank you for your assistance.

Start Date

End Date

Final Position/Title

Final Salary

Time in Final Pay Grade

Your Relationship to Employee

Position Summary:

Essential Job Functions:

Reason for Leaving:

Is this Individual Eligible for Rehire?YesNo If no, please explain:

Please Describe this Individual’s Most Valuable Attributes:

What Is Your Opinion of this Individual’s Ability to Add Value to Our Company?

Signature

Date

Printed Name:

Title: