Position Held: ____________________________________________
Dates Employed From: ___________________ to _______________
Pay Rate: ____________________
Reason for Leaving: ____________________________________________________________
Eligible for Re-Employment? (Circle One) Yes No If No, Explain: _____________________
Additional Information/Comments:_________________________________________________________
____________________________________________________________________________
Attendance: (Circle One) Poor Fair Good Excellent
Reliability: (Circle One) Poor Fair Good Excellent
Attitude: (Circle One) Poor Fair Good Excellent
Skill Knowledge : (Circle One) Poor Fair Good Excellent
Name of Person Completing this Form: ____________________________________________
Title: ____________________________ Contact Number: ___________________________
Thank You, Your Time and Consideration is Appreciated
eKidzCare Employee: _____________________________ Date: _____________
Title: ___________________ Contact Information: _________________________________