Apd-19 - Request For Applicant'S Employment Record Form Page 2
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1
2NAME OF FIRM OR AGENCY
TYPE OF BUSINESS OR FUNCTION OF AGENCY
DATE
EMPLOYED
PART TIME
AVERAGE
OR
FROM
TO
FULL TIME
TITLE OR DUTY
WEEKLY SALARY
SOCIAL SECURITY NO.
IF NOT PRESENTLY EMPLOYED BY YOU, INDICATE MANNER OF LEAVING YOUR EMPLOY
(Check One)
RESIGNED VOLUNTARILY (State reason given.)__________________________________________________
REQUESTED TO RESIGN (State reason.)_______________________________________________________
}
DISCHARGED
_______________________________________________________________
Please
specify
LAID OFF
________________________________________________________________
reason
OTHER
________________________________________________________________
CANDIDATE’S EMPLOYMENT RECORD
(Check yes or no. If you desire to elaborate, do so in “details.”)
Honest
Yes
Amenable
Yes
Excessively
Yes
Was He
Yes
No
To Orders
No
Late
No
Ever
No
Disciplined
Sober
Yes
Able To Get
Yes
Excessively
Yes
Injured or
Yes
No
Along With
No
Absent
No
Given First
No
Others
Aid
IS SUBJECT CONSIDERED
Yes
WOULD YOU PREFER A PERSONAL
Yes
“ELIGIBLE FOR REHIRE”?
No
INTERVIEW TO DISCUSS THE CANDIDATE?
No
DETAILS OR ADDITIONAL COMMENT:
RESIDENCE
ADDRESSES WHILE
IN YOUR EMPLOY
NAMES AND
ADDRESS
OF PREVIOUS
EMPLOYERS
SIGNATURE
TITLE OF YOUR POSITION
YOUR BUSINESS TELEPHONE NO.
REQUEST FOR APPLICANT’S EMPLOYMENT RECORD
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Parent category: Business