Sample of a Reference Check Form

Applicant Name ............................................................
Company Contacted.....................................Date.................…………..
Person Contacted.............................Title......................................…….

1- Dates of Employment From............................To..............................……..
2- Positions & Duties Held..............................................................………….
3- Attendance Record Poor Average Good
4- Reasons for Termination Discharged Resigned
5- Job Performance Rating Poor Average Good
6- Friendliness Distant Approachable Warm
7- Attitude Uncooperative Cooperative
8- Knowledge of Field Poor Average Good
9- Strengths and Weaknesses.....................................................
10- Any Additional Information Obtained.........................................

Signature of Person Conducting Reference Check..................

Sample of a Reference Check Form