APP-09 – Previous Employer Reference (1)

HOME COMPANION SERVICES

APP-09 – Previous Employer Reference (1) STEP-09
Home Companion Services

46 Route 25A, Suite 8 East Setauket, NY 11733
631-473-0700/1-800-473-4HCS(4427) Fax# 631-473-9507
The applicant named below has applied for a position with our organization and has listed you as a previous employer. In order for us here at Home Companion Services to maintain our high standards, and because of the sensitive nature of our business, we ask you to evaluate this applicant’s job performance as well as his/her personal integrity. We thank you for taking the time to return this to us, and assure you that information provided will be held in strict confidence. Thank you!
TO BE COMPLETED BY REFERENCE
Does the information below correspond with your records?
Would you rehire this employee?
If not, please explain
Please Evaluate Circle Only One
Attendance:

ExcellentGoodAveragePoor
Punctuality:

ExcellentGoodAveragePoor
Reliability :

ExcellentGoodAveragePoor
Integrity:

ExcellentGoodAveragePoor
Empathy:

ExcellentGoodAveragePoor
What is your relationship to the Applicant?
Reference Signature

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Position
TO BE COMPLETED BY APPLICANT
Applicant Name:
Last four digits of Social Security Number:
Previous Employer Name:
Reference Full Address:
Reference Email Address:
example@example.com
Dates of Employment From:

MonthDayYear
Date
To:

MonthDayYear
Date
Position Held
Wage Rate
Please describe your reason for leaving
I hereby authorize you to disclose all and any information concerning my employment to Home Companion Services. I understand this is in accordance with all applicable Federal and State Laws.
Applicant’s Signature:

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Date

MonthDayYear
Date
Should be Empty:

HOME COMPANION SERVICES

TO BE COMPLETED BY REFERENCE

TO BE COMPLETED BY APPLICANT