P O Box 11205 / Jackson TN 38308-0120 731-664-0983 731-664-2433 (fax) EMPLOYMENT VERIFICATION (Return Fax to 731-668-2433) Reference Release Form To: Fax: From: Nancy Riggs, Human Resources Director Madison-Haywood Developmental Services 139 Stonebridge Blvd., P.O. Box 11205 Jackson, TN 38308-0120 731-984-6404 Office 731-668-2433 Fax Date: Applicants Name: __________________________________________________________SS#_______________________________ The above named applicant is being considered for employment with Madison-Haywood Developmental Services, and has listed your organization as a former employer. We would appreciate your verification and completion of this form at your earliest convenience. Applicant’s Authorization I consent to and authorize the above named former employer, and its agents and employees, to furnish any reference information concerning me, including achievements, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment. I also hereby release the above name former employer, and its agents, and employees, from all liability for damages or claims, including but not limited to defamation, interference with contract, or prospective economic advantage and negligence, I have or may have which arise or result from any reference information provided pursuant to this authorization or any attempts to comply with this information. Applicant’s Signature: _________________________________________ Date: ____________________ Thank you for your assistance. This information is kept confidential. ************************APPLICANT’S DO NOT WRITE BELOW THIS LINE************************************ Record of Employment Position held: ______________________________________Dates employed: to Reason for leaving: ____________________________________________________________________ Salary at termination: ______________________ Eligible for rehire? ______yes ______no Is this individual under any known investigation? ______YES Please rate the following: Job Knowledge Accuracy Productivity Dependability Attendance Overall Performance Verifying Individual’s Signature: Excellent _________ _______ __ _______ __ _______ __ _______ __ _______ __ Good ______ ______ ______ ______ ______ ______ Average _______ _______ _______ _______ _______ _______ NO Fair Poor _______ _______ _______ _______ ________ _______ ________ _______ ________ _______ ________ _______ Title: Thank you for your response. Please fax form back to Nancy Riggs, HR Director. @ 731-668-2433.
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