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November 13, 2016

[FORMER EMPLOYER NAME]

Address
Address2
City, State/Province
Zip/Postal Code

OBJECT: REFERENCE CHECK FOR [APPLICANT NAME] [SOCIAL SECURITY NUMBER]

Dear [FORMER EMPLOYER NAME],

A former employee of your company, [APPLICANT NAME], has applied for a position with our company.
As part of interview process, we are hereby requesting background information from you on this
employee. [HE/SHE] has given us permission to request such information from you and a copy of such
request is attached hereto.
Please provide us the following information concerning this former employee:
Dates of employment:

Positions held:

Responsibilities:
Last total salary and bonus while employed:
Reason given for terminated/leaving:
How would you rate his/her overall competence? (Check one.)
Outstanding
Good
Average
Fair

Poor

Please state briefly what you believe to be his/her greatest strengths and weaknesses (if any):
Strengths
Weaknesses
If you had an opening for which he/she is qualified, would you rehire him/her? Yes
If no, please state why.

No

I assure that any information you supply about this applicant will be held in strict confidence. If there is
ever an opportunity for me to reciprocate, I will be pleased to do so. We will need this information as soon
as possible, and thus we would appreciate if you could fax the response to the undersigned at [FAX
NUMBER]. Thank you for your consideration.
Sincerely,

Your name
Your title
(800) 123-4567
youremail@yourcompany.com
Company Name
Street, City, State/Province, Zip/Postal code
Tel: (000) 000-0000 / Fax: (000) 000-0000
www.yourwebsite.com