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REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER

 

From:___________________________________________________

To:_____________________________________________________

Date:___________________________________________________

Social Security Number:___________________________________

 

________________ has made application to this company for a position as __________ and states that he/she was employed by you as ______ from ___ to __________. Will you please reply to the inquiry below respecting this applicant. Your reply will be held in strict confidence and will in no way involve you in any responsibility. For you convenience in replying by return mail, we have enclosed a stamped self-addressed envelope.

 

Very truly yours,

Safety Department

 

  1. Is the employment record with your company correct as stated above? __________________________
  2. 2. What kind(s) of work did the applicant do? __________________________
  3. Did the applicant drive motor vehicles for you? Passenger Car, Straing truck, Bus, Tractor-Semitrailer, Other (specify) __________________________
  4. Was the applicant a safe and efficient driver? __________________________
  5. Give the dates of vehicle accidents in which he/she was involved. __________________________
  6. Reason for leaving your employ: Discharged, Laid off, Resigned, Remarks: __________________________
  7. Was the applicant’s general condust satisfactory? __________________________
  8. Is the applicant competent for the position sought? __________________________
  9. Did the applicant drink any alcoholic beverages while on duty? __________________________

 

  Excellent Good Fair Poor Very Poor
Quality of work
          
Cooperation with others
          
Safety habits
          
Personal habits
          
Driving skill
          
Attitiude
          

    

 

Remarks:________________________________

Date:____________________________________

Signature:________________________________

Name of Company: (Detach here for your records.) _________________________________

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(Name of Former Employer)_________________________________________ Date: ______

 

You are hereby authorized to give to (Name of Prospective Employer) __________________ all information regarding my services, character, and conduct while in your employ, and you are released from any and all liability which may result from furnishing such information to the above named company.