PETERSBURG CITY PUBLIC SCHOOLS
HUMAN RESOURCES DEPARTMENT
EMPLOYMENT REFERENCE FORM
PART 1-TO BE COMPLETED BY APPLICANT
I am applying for a position as __________________________________with the Petersburg City Public Schools. Please
complete the appropriate evaluation categories that apply to your knowledge of my background and mail to Petersburg City
Public Schools, Human Resources Department, 255 South Boulevard East, Petersburg, VA 23805-2700 or you may email
them to
pcpsapplications@petersburg.k12.va.us
Name of Applicant ____________________________________________________________________________________
I give permission for information pertaining to my work experience to be released to the Petersburg City Public Schools, and
I release the evaluator and the Petersburg City Public Schools from liability for using that information. I understand that the
evaluator will be providing this information on a confidential basis to the Petersburg City Public Schools, and not to me, and
I waive any right that I may have to review this reference.
Signature of Applicant ______________________________________________ Date ______________________
PART II-TO BE COMPLETED BY EVALUATOR
Type of Position Held by Applicant _______________________________________________________________________
Dates of Service:
From (Mo ./Yr.)___________________________________
To (Mo. /Yr.) _______________________________
If no longer an employee, reason for leaving: ________________________________________________________________
Professional Competence
Outstanding
Above Average
Average
Adequate
N/A
Effectiveness in the Job
Communication
Classroom Management
Initiative
Competence
Professional
Maturity of Judgment
Dependability
Collaborative
For Positions of Leadership
Managerial/Organizational Skills
Leadership Ability
Would you reemploy at the same position? Yes________ No _________
Comments
Name ___________________________________________
Title____________________________
Signature________________________________________
Date____________________________