the employee verification reference release form here

P O Box 11205 / Jackson TN 38308-0120
731-664-0983
731-664-2433 (fax)
EMPLOYMENT VERIFICATION
(Return Fax to 731-668-2433)
Reference Release Form
To:
Fax:
From:
Nancy Riggs, Human Resources Director
Madison-Haywood Developmental Services
139 Stonebridge Blvd., P.O. Box 11205 Jackson, TN 38308-0120
731-984-6404 Office
731-668-2433 Fax
Date:
Applicants Name: __________________________________________________________SS#_______________________________
The above named applicant is being considered for employment with Madison-Haywood Developmental Services, and has listed your
organization as a former employer. We would appreciate your verification and completion of this form at your earliest convenience.
Applicant’s Authorization
I consent to and authorize the above named former employer, and its agents and employees, to furnish any reference information
concerning me, including achievements, wage history, performance, attendance, personal history, disciplinary information and reason
for separation of employment. It is expressly understood that any information given is to be used for the purpose of determining my
acceptability for employment. I also hereby release the above name former employer, and its agents, and employees, from all liability
for damages or claims, including but not limited to defamation, interference with contract, or prospective economic advantage and
negligence, I have or may have which arise or result from any reference information provided pursuant to this authorization or any
attempts to comply with this information.
Applicant’s Signature: _________________________________________ Date: ____________________
Thank you for your assistance. This information is kept confidential.
************************APPLICANT’S DO NOT WRITE BELOW THIS LINE************************************
Record of Employment
Position held: ______________________________________Dates employed:
to
Reason for leaving: ____________________________________________________________________
Salary at termination: ______________________ Eligible for rehire? ______yes ______no
Is this individual under any known investigation? ______YES
Please rate the following:
Job Knowledge
Accuracy
Productivity
Dependability
Attendance
Overall Performance
Verifying Individual’s Signature:
Excellent
_________
_______ __
_______ __
_______ __
_______ __
_______ __
Good
______
______
______
______
______
______
Average
_______
_______
_______
_______
_______
_______
NO
Fair
Poor
_______
_______
_______
_______
________ _______
________ _______
________ _______
________ _______
Title:
Thank you for your response. Please fax form back to Nancy Riggs, HR Director. @ 731-668-2433.