Dear

The person identified below is being considered for
employment and has signed a statement authorizing this
verification and investigation. We shall appreciate a
statement of your opinions and experiences as outlined
below. Your reply will be considered confidential.

___________________________________
Name of Applicant

___________________________________
Social Security Number

___________________________________
Dates of Claimed Employment

___________________________________
Position Last Held

___________________________________
Final Rate of Pay

Is the above information correct? Yes______ No________
If not please make corrections.

What is your opinion as to this person’s

Ability________________________Effort_________________________

Conduct________________________Attendance_____________________

Reason for leaving your employ________________________________
______________________________________________________________

Eligible for rehire? Yes_____No_____If not, why?_____________
______________________________________________________________

Your further comments on any personal or professional strength
and weaknesses will be appreciated.___________________________
______________________________________________________________
______________________________________________________________

Date__________Signed_____________________Title________________

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