REFERENCE CHECK FORM
Date of Reference Name of Company
Your Name Name of Reference __________________________
Name of
Candidate Title of Reference
Position Applied Relationship to
For Candidate
PLEASE VERIFY THE FOLLOWING (refer to resume/application)
(Circle or BOLD)
Previous Job Title YES NO
Dates of
Employment YES NO
Reason for Leaving YES NO
PLEASE ELABORATE (site examples as necessary)
Quality of Work.
Initiative/Follow-through (specific examples):
Ability to Work with Others (i.e. co-workers, patients):
Ability to Handle Stress/Performance Under Pressure:
Example of a time where managed a project from start to finish:
Response to Supervision:
Organizational Ability:
Attendance Habits:
Strengths:
Opportunities for Improvement:
Eligible for re-
employment (Yes or No)
If no, please explain why: