Name of applicant:     _______________________________

Place of employment:     _____________________________

Person contacted:

(Title)     _______________________________________

Telephone number:    _____________________________

Dates of employment:     _____________________________

Title:     ___________________________________________

How long in that position:    __________________________

Duties:     _________________________________________

Comments

Quality of work:    ___________________________________

Quantity of work:   ___________________________________

Attendance record: __________________________________

Punctuality:     ______________________________________

Ability to get along w/peers:   ____________________________

Supervision given or received:  __________________________

Reason for leaving: ___________________________________

Would you rehire: Yes_____ No_____ Explain:

Additional comments:     _____________________________
_______________________________________________
_______________________________________________
_______________________________________________

Salary: ___________________________________

Checked by: ___________________________________

Date: ___________________________________