Applicant Name: Date of Reference Check: Person Checking Reference: Reference Name: Reference Organization: Relationship to Applicant: Supervisor Peer Other (Specify) Dates of Employment: From To Salary: Position(s) Held: What was the nature of the applicant’s job Reason for Separation: Voluntary Involuntary Give Explanation: Please rank the candidate based on the following areas: Responds to Supervision Attendance Dependability Willingness to assume responsibility Ability to follow instructions Quality of work Quantity of work Poor Poor Poor Poor Poor Poor Poor Fair Fair Fair Fair Fair Fair Fair Good Good Good Good Good Good Good Very Good Very Good Very Good Very Good Very Good Very Good Very Good Excellent Excellent Excellent Excellent Excellent Excellent Excellent N/A N/A N/A N/A N/A N/A N/A Additional Questions: Were there any disciplinary actions Please explain: Were there any performance issues Please explain: What are the candidate’s strong points What are the candidate’s weak points If given the opportunity, would you re-employ this individual Any additional comments Yes No.
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