3 - REFERENCE REQUEST FORM

REFERENCE REQUEST
Please complete this form
Employee Name
Previous Employer Name
Previous Employer Address
Previous Employer Telephone Number
Format: (000) 000-0000.
Fax
I have applied to .
for a position as a .
I authorize you to respond to the questions below so they may act on my application. I release you from all liability

in supplying this information regarding my employment with you.
Print Applicant’s Name
Applicant’s Signature:

Clear
Date:

MonthDayYear
Date
I’ve worked for your company from

MonthDayYear
Date
to

MonthDayYear
Date
as a
(To be completed by former Employer)
YesNo
YesNo
If not please explain :