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ARIZONA DEPARTMENT OF ADMINISTRATION PRE EMPLOYMENT REFERENCE CHECKS IMPORTANT ­ PLEASE READ
To former employers: I hereby authorize you to disclose any information about my employment with your organization to the State of Arizona. Such information includes my performance evaluations and any disciplinary action and I agree to release and hold harmless you and your organization from all liability arising from such disclosure. Printed Name:
First Middle Initial Last

Applicant's Signature:

Date

Applicant: Below, please provide the name and contact numbers of your last three supervisors, starting with your current or most recent supervisor. Include dates of employment. Name (Current/most recent): Phone No.: Company/Agency:

Fax No.:

Dates of Employment: From To

Name:

Phone No.:

Company/Agency:

Fax No.:

Dates of Employment: From To

Name:

Phone No.:

Company/Agency:

Fax No.:

Dates of Employment: From To

Hiring Authority: Verify all degrees, special certifications, licenses, etc., if required for position for which candidate is being considered. NOTE: A monetary charge could be assessed by the institution providing the verification documentation. Type of degree, license, or certification: ________________________________________________________________ Expiration Date (if applicable): _________________________________________________________ Name of school or credentialing organization: ____________________________________________________ If required, school/organizations: Phone No.: _________________________________________ Fax No.: _________________________________________ E-mail.: _________________________________________ Address: _________________________________________ Applicant provided a copy of degree, license, or certification: Information verified with school/organization: Additional information provided by school/organization: YES YES NO NO

Verification completed by _______________________________________

Date: ______________________________

Hiring Authority: If applicant is a current or former state employee, or a Department employee, an official personnel file review is required. NOTE: Not applicable to Universities. Personnel File Review: Covered Employee Last Evaluation: Date: ___________________________________ Overall Score: ___________________________________ Uncovered Employee

Evaluation Comments:

Previous Evaluation: Date: ___________________________________ Overall Score: ___________________________________

Evaluation Comments:

Personnel file indicates employee received: Letters of Commendation Disciplinary Letters Comments: YES YES NO NO

Personnel file review completed by ___________________________________

Date: ______________________________

Attachments:

Reference Check Form

Effective Date: September 1, 2008

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REFERENCE CHECK FORM
Applicant's Name: Date of Reference Check:

Person Contacted:

Position/Title of Reference:

Organization:

Phone No:

Identify yourself and the candidate and tell the reference about the position that is being filled. 1. What was/is your working relationship with the applicant? (i.e., supervisor, co-worker, etc.)

2. During what time period did the applicant work for you or with you?

3. How would you describe the applicant's: Attendance:

Dependability:

Capacity for discretion/good judgment:

Accuracy:

Supervisory responsibility, if applicable:

Ability to get along with others:

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4. What do you believe are this individuals strengths and/or skills:

5. What areas could the individual improve upon:

6. How would you characterize his/her work in general:

7. Why did this person leave the job:

8. Would you rehire this individual?

YES

NO Date: ________________

Reference check completed by ___________________________________

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