Name of applicant: ________________________________________

Person contacted:  ________________________________________

Company:             ________________________________________

Position/Title:       ________________________________________  Phone #: _________________

1. What were the dates of his/her employment with you? Salary?

2. What was the nature of his/her job?

3. What did you think of his/her work?

4. How would you describe his/her performance in comparison with other people/team members?

5. What areas of progress did he/she make that you would point to?

6. Why did he/she leave your company?

7. What would you think about re-employing him/her?

8. What are his/her strong points?

9. What are his/her limitations or areas requiring improvement?

10. How did he/she get along with other people?

11. What would you say about his/her:

- attendance

- dependability

- ability to take on responsibility

- potential for advancement

- degree of supervision needed

- overall attitude

12. Is there anything else of significance we should know?
 

Reference checked by: ________________________________  Date: _____________________