Request for Verification of Prior Work

The person identified below is being considered for employment and has signed a statement authorizing this verification and investigation. We shall appreciate a brief statement of your opinions and experiences as outlined below. Please complete as many of the information request areas as you can and then [email your response when finished; mail your response in the Self-addressed Stamped Envelope]. It should take only a few minutes of your time.

Of course, all your comments will be kept confidential.

Name of Applicant: [name]
Social Security Number: XXX-XX-XXXX
Dates of Claimed Employment: [dates]
Position Last Held: [position]
Final Rate of Pay: $[XXX] per month.

Is the above information correct? Yes____ No____ . If not please make corrections.

What is your opinion of this person in terms of:

Ability: [provide one or two blank lines]
Effort: [provide one or two blank lines]
Conduct: [provide one or two blank lines]
Attendance: [provide one or two blank lines]

Reason for Leaving your Employ:

Eligible for rehire? Yes____ No____. If not, please explain why?
[provide several blank lines]

Your further comments on any personal or professional strength and weaknesses will be appreciated.
[provide several blank lines]