Form Pd 407-163 - Request For Applicant'S Employment Record 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.”)
Yes
Yes
Yes
Yes
Honest
Amenable
Excessively
Was He
No
No
No
No
To Orders
Late
Ever
Disciplined
Yes
Yes
Yes
Yes
Sober
Able To Get
Excessively
Injured or
No
No
No
No
Along With
Absent
Given First
Others
Aid
Yes
Yes
IS SUBJECT CONSIDERED
WOULD YOU PREFER A PERSONAL
No
No
“ELIGIBLE FOR REHIRE”?
INTERVIEW TO DISCUSS THE CANDIDATE?
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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