ATA Recruiters ~ Job Seekers ~ Reference Check

ATARecruiters.com
A Total Approach to Recruitment and Retention Nationwide

Complete, Sign and Fax these forms to:
Toll Free: (888) 900-7708, or Local: (714) 828-8964

Authorization Date:

Print Your Full Name:

Print Former Full Name (if applicable):

Address, Apartment/Suite:

City, State, Zip:

Telephone:

Applicant's Signature:

EDUCATION

School Attended:

Address of School:

Major:

Degree or Diploma? Yes:______ No: ______

Dates of Attendance:

LICENSURE

If you are certified, licensed or registered to practice in your field, please provide:

TYPE of License:

Applicable State(s):

License by State: #_______________________ Expires: ___ / ___ / ___

Other applicable information:

I herby certify that the information contained in this form is true and correct to the best of my knowledge and agree to have any statements checked by ATA unless I have indicated to the contrary. I authorize any and all former employers to release all employee records, reports and other information related to my work records, including health records requested. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the company as well as from the sue or disclosure to such information by the company or any of its agents, employees or representatives.

Signature:

ATA Recruiters.com
A Total Approach to Recruitment and Retention Nationwide

Authorization Date:

Print Your Full Name:

Print Former Full Name (if applicable):

ID # (if applicable):

Applicant's Signature:

Organization Where Formerly Employed:

The person listed above has applied to us for our professional services and states you are familiar with her/his work performance. Will you please assist us in complying with best business practice standards, by completing this form and returning it to us as soon as possible? You may also give us this information by phone.

Title/Position Held:

Rate of Pay:

Dates of Employment: ___ / ___ / ___ to: ___ / ___ / ___

Status Full Time: ____ Part Time: ____ Per Diem: ____ Other, List: _____________

Please rate the following:
	Improvement Needed =1	Average =2	Good =3	Excellent =4
Quantity/Quality of Work
Attitude/Cooperation
Attendance/Punctuality
Professional Demeanor Clinical Skills/Knowledge

Additional Comments:

Reason for Separation:

Would you rehire? Yes: ____ No: ____
If not, please state reason:

Name of Reference:
Title:

Signature:

Telephone Reference Verified:
Yes: ____ No: ____
Name: ______________________________ Date: ___ / ___ / ___

ATA Recruiters.com
A Total Approach to Recruitment and Retention Nationwide

Authorization Date:

Print Your Full Name:

To Whom It May Concern:
I hereby authorize and request any present or former employer, school or other persons having any personal knowledge about me, to furnish bearer with any and all information in their possession regarding me in connection with application for employment. I am willing that a photocopy of this authorization will be accepted with the same authority as the original and I specifically waive any written notice from any present or former employer who may provide information based upon this authorized request. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the company as well as from the sue or disclosure to such information by the company or any of its agents, employees or representatives.

Applicant's Signature:

Reference's Name:

The person listed above has applied for the position of ___________________, and your name was given as a reference.

We would appreciate your answering the following questions:

1. How long have you known/supervised this person?

2. What was the position held at the time of leaving your organization?

3. What reason was given for leaving? __________________________________________

4. How would you rate his/her overall competence?
Check One
Outstanding: ____ Good: ____ Average: ____ Fair: ____ Poor: ____

5. Please state briefly what you believe to be her greatest strengths and weaknesses (if any):

Strengths:

Weaknesses:

6. If you had an opening for which she qualified, would you rehire her?
Yes: ____ No: ____
If no, please state why:

Signature:

If there is ever an opportunity for us to be of assistance to you or your organization, we will welcome the opportunity to do so.