1821 S Bascom Avenue #283, Campbell 95008(P) 408-689-8132
TO WHOM IT MAY CONCERN:
The applicant named below has submitted an application for employment with our company. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.
TO BE FILLED OUT BY APPLICANT:
Application Name: First Name* Last Name*
Previous Employer who we can contact: Employer*
Contact Person: First Name* Last Name*
I hereby authorize the following information to be released. I relase you and all persons and organizations from all claims and liabilities of any nature from any information given.
FOR OFFICE USE ONLY:
Date of Employment: From: Date to Date Position Held: Type a label Responsibilities: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Reason for Leaving: Type a label Eligible for Rehire: Type a label Reference for Leaving: Type a label Eligible for Rehire: Type a label Reference Check By: Type a label Signature: Signature Date: Date
SPECIAL INSTRUCTIONS:
EMERGENCY CONTACTS
Primary Contact in case of Emergency:First Name* Last Name* Area Code* Phone Number*
EMPLOYEE AUTHORIZATION:
I have voluntarily provided the above contact information and authorized Bayhealth, Inc and its representative to contact any of the above individuals on my behalf in the event of an emergency.
Employee Name: First Name Last Name
License/Certificate #: Expires: Date Status/Comments:
TO BE COMPLETED BY EMPLOYER:
Verification Numbers and Websites