SECURING AND PROVIDING EMPLOYMENT REFERENCE INFORMATION
SAMPLE REFERENCE REQUEST

TO: {Name/Company}
    {Mailing Address}
    {Attention:}

RE: {Name of Applicant}

The individual named above has applied for employment with the {Department/Division name} as a {job title/
position classification} and has given your name/company as a contact for an employment reference. 

1. How are you acquainted with the applicant?

______ As a current or former employer (Please complete parts 2 and 4).

______ Other (Please complete parts 3 and 4).

2. If supervisor or employer, please provide the following information.

a. Dates of employment: FROM ________________ TO ________________

b. Position for which initially employed:  _________________________________

c. Last position held: _____________________________________________________

d. Description of job duties and responsibilities:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

e. Reason individual left your employment:

[ ] To accept other employment                    [ ] Dismissed
[ ] Resigned                                      [ ] Other (please specify)
[ ] Resigned under threat of disciplinary action __________________________

f. Is individual still employed:    YES _______    NO ________

g. Please have completed by immediate supervisor if (s)he is still employed, or by personnel office, if supervisor is no longer with company.

                                Excellent  Good  Average  Fair  Poor
   Quality of work                 [ ]      [ ]    [ ]    [ ]   [ ]
   Quantity of work                [ ]      [ ]    [ ]    [ ]   [ ]
   Attendance & punctuality        [ ]      [ ]    [ ]    [ ]   [ ]
   Conduct                         [ ]      [ ]    [ ]    [ ]   [ ]
   _____________________           [ ]      [ ]    [ ]    [ ]   [ ]
   _____________________           [ ]      [ ]    [ ]    [ ]   [ ]

Please comment on any rating of “Poor,” and feel free to comment on any area rated better than “Average.” Comments may be made on a separate sheet or on the reverse side of this letter.

h. Would you re-employ:    YES _______ NO ________
If no, please explain: _____________________________________________________

3. Other: Academic/Volunteer/Work Reference

a. Dates you have known applicant: FROM _______________ TO _______________

b. How were you associated with the applicant (teacher, volunteer coordinator)? ________________________________________________________

c. Based on the association you have had with the applicant, please describe the characteristics of the applicant which, in your opinion, you think would help him/her succeed in this position or would be an asset to this agency should an employment offer be made.
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

d. Please complete the following if you have had sufficient opportunity to observe and evaluate the applicant.

                                Excellent  Good  Average  Fair  Poor
   Quality of work                 [ ]      [ ]    [ ]    [ ]   [ ]
   Quantity of work                [ ]      [ ]    [ ]    [ ]   [ ]
   Attendance & punctuality        [ ]      [ ]    [ ]    [ ]   [ ]
   Conduct                         [ ]      [ ]    [ ]    [ ]   [ ]
   _____________________           [ ]      [ ]    [ ]    [ ]   [ ]
   _____________________           [ ]      [ ]    [ ]    [ ]   [ ]

4. Completed by:

   Name: _________________________________________________________________

   Job Title (if applicable): ____________________________________________

   Signature: ____________________________________________________________

   Date: ______________________ Business Phone Number : __________________

PLEASE RETURN COMPLETED INFORMATION TO:
         {Department/Division Name}
         {Mailing Address}
         {Attention:}

To ensure confidentiality, you may use the enclosed pre-addressed envelope.