Reference Check Control Form

Applicant Name:  _____________________________________	Position: _____________________

Personal references checked:

Name:		______________________________	Relationship:  _______________________________
Address :	______________________________________________________________________________
Telephone:	_____________    Date contacted:	_____________  Method of contact:  ___________________
Notes:___________________________________________________________________________________________________________________________________________________________________________________

Name:		______________________________	Relationship:  _______________________________
Address :	______________________________________________________________________________
Telephone:	_____________    Date contacted:	_____________  Method of contact:  ___________________
Notes:___________________________________________________________________________________________________________________________________________________________________________________

Name:		______________________________	Relationship:  _______________________________
Address :	______________________________________________________________________________
Telephone:	_____________    Date contacted:	_____________  Method of contact:  ___________________
Notes:___________________________________________________________________________________________________________________________________________________________________________________

Employment references checked:

Name:		______________________________  Employer: ______________________________________
Relationship:  ________________________  Dates of employment:  _______________Pay: __________________
Address :	______________________________________________________________________________
Telephone:	_____________    Date contacted:	_____________  Method of contact:  ___________________
Would you rehire?   ___________	  Reason for termination:  ___________________________________________
Notes:___________________________________________________________________________________________________________________________________________________________________________________

Name:		______________________________  Employer: ______________________________________
Relationship:  ________________________  Dates of employment:  _______________Pay: __________________
Address :	______________________________________________________________________________
Telephone:	_____________    Date contacted:	_____________  Method of contact:  ___________________
Would you rehire?   ___________	  Reason for termination:  ___________________________________________
Notes:___________________________________________________________________________________________________________________________________________________________________________________

Name:		______________________________  Employer: ______________________________________
Relationship:  ________________________  Dates of employment:  _______________Pay: __________________
Address :	______________________________________________________________________________
Telephone:	_____________    Date contacted:	_____________  Method of contact:  ___________________
Would you rehire?   ___________	  Reason for termination:  ___________________________________________
Notes:___________________________________________________________________________________________________________________________________________________________________________________

Records checked:

•	School records  (date requested:  ____________)  Notes: ___________________________________________
•	Criminal records (date requested: ____________) Notes: ___________________________________________
•	Driving records (date requested: _____________) Notes: ___________________________________________
•	Credit records (date requested: ______________) Notes: ___________________________________________