• JOURNEYS IN COMMUNITY LIVING: EMPLOYER REFERENCE INFORMATION REQUEST

  • Applicant: Sign Authorization, Date and Sign with Adobe Sign at the end of this form ONLY! Other fields are for Journeys and your former employer's use only.

  • Date: _________________________________________
    To: _________________________________________
      _________________________________________
      _________________________________________
    Re: Employer Information Request

  • ___________________________________ SS# XXX-XX-__________ has applied for a position with Journeys in Community Living (formerly the Rutherford County Adult Activity Center), a support program for adults with disabilities and has given your name as a current/former employer. Please return this form at your earliest convenience by fax (615-849-8727) or email (rachel.burch@journeystn.org).

    Thank you for your assistance!

    ___________________________________
    Name & Title

  • REFERENCE INFORMATION

    Title of position applicant was hired or title of position applicant left

    		  
     Employment Dates?  From:IIIIIIIIIIIIIIIIIIIIIIIIIIITo:IIIIIIIIIIIIIII
     Hours per week applicant worked?  
     Reason applicant left company?  
     Would you rehire?  
     If no, why not?  

  • PERFORMANCE QUESTIONS

      ABOVE AVERAGE AVERAGE BELOW AVERAGE UNSATIS-FACTORY
    Quality of work        
    Cooperation        
    Communication Skills        
    Responsibility for self        
    Relationship with peers        
    Relationship with supervisor        
    Professional Conduct        
    Punctuality        
    Attendance        
    Supervisory skills        

  • Additional Comments:

     
  • ____________________________________________________   __________________
    Signature and Title of Person Completing this Form   Date
  • Clear
  •  - -

  • APPLICANT: You must enter your email address and sign this form using Adobe Sign below for us to receive your form. After you submit this form, you will be automatically redirected to our Employment home page to continue signing any other needed forms.

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