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: __________________________________