REFERENCE CHECK FORM
Reference #1 of 2
TO:
Name of Applicant: ________________________________________________________________ SS# ____________________________
has applied for employment with our company. Please assist us in making a decision regarding employment that will best benefit this applicant and our organization by providing the requested information below.
Sincerely ____________________________________________________________________Date: _______________________________
I voluntarily give CAPITOL HOME HEALTH the right to investigate my past and/or present employment and release from all liability or responsibility by all persons, companies, or organizations supplying information.
Applicant Signature: _______________________________________________________________________________________________
FOR OFFICE USE ONLY: ________________________________Employment Dates: ______________________________
Eligible for rehire? ___ YES ___ NO
Position Held: ________________________________ Final Salary: $________________________________
Reason for termination/separation: ___________________________________________________________________________________
Please rate this individual on the basis of his/her employment with you:
Quality of Work: ___ Exceptional ___ Satisfactory ___ Unsatisfactory
Ability: ___ Exceptional ___ Satisfactory ___ Unsatisfactory
Attendance: ___ Exceptional ___ Satisfactory ___ Unsatisfactory
References Information Provided By: _________________________________Job Title: ______________________
Verified by: ___ Phone ___ Mail
Verified By: _________________________________________ Job Title: __________________________________
Reference #2 of 2
TO:
Name of Applicant: ________________________________________________________________ SS# ____________________________
has applied for employment with our company. Please assist us in making a decision regarding employment that will best benefit this applicant and our organization by providing the requested information below.
Sincerely ____________________________________________________________________Date: _______________________________
I voluntarily give CAPITOL HOME HEALTH the right to investigate my past and/or present employment and release from all liability or responsibility by all persons, companies, or organizations supplying information.
Applicant Signature: _______________________________________________________________________________________________
FOR OFFICE USE ONLY: ________________________________Employment Dates: ______________________________
Eligible for rehire? ___ YES ___ NO
Position Held: ________________________________ Final Salary: $________________________________
Reason for termination/separation: ___________________________________________________________________________________
Please rate this individual on the basis of his/her employment with you:
Quality of Work: ___ Exceptional ___ Satisfactory ___ Unsatisfactory
Ability: ___ Exceptional ___ Satisfactory ___ Unsatisfactory
Attendance: ___ Exceptional ___ Satisfactory ___ Unsatisfactory
References Information Provided By: _________________________________Job Title: ______________________
Verified by: ___ Phone ___ Mail
Verified By: _________________________________________ Job Title: __________________________________