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________________