Applicant
name:
Former
employer:
Social
Security No: Dates
employed:
The above applicant is being
considered for employment with and
has listed your organization as a former employer. We would appreciate your
completion of this form at your earliest convenience.
The Information you provide will be treated in confidence. Please return this form to
us in the enclosed, self-addressed, stamped envelope. Thank you for your
assistance.
Applicant's Authorization
I authorize my former employer, and its agents and employees, to provide
information about my work performance, wage history, attendance, personal
history, disciplinary information and reason for separation of employment. The
information is for the purpose of determining my acceptability for employment. I
also hereby release the above named former employer, and its agents and
employees, from all liability for damages or claims, including but not limited
to defamation, interference with contract, or prospective economic advantage and
negligence, which may arise or result from any reference information provided
pursuant to this authorization.
Applicant's signature:
Date:
Record of
Employment
Position
held: Dates
employed:
Summary of
applicant's duties:
Reason for
leaving:
Salary at
termination:
Eligible for rehire? ____ Yes ____ No
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Comments:
Signature: Title: Date: