initials Investigator’s Print clearly and use black ink only 4th former employer or period of unemployment Name of former employer Former mailing address employer’s Start Date / End Date / Month Year Month Year Full time Part-Time Temporary Military Self-Employed Volunteer Internship Unemployed Former telephone number for employment verification (Personnel) Your title or position employer’s Telephone number ( ) Area code Reason for leaving employment Resigned to take better position Lay off Contract expired Return to school Terminated (fired) Completion of military service Resigned to avoid being terminated Resigned while under investigation Quit without giving notice as required by company policy Reason not listed, explain below Explain reason for leaving employment; continue on page twenty-nine (29) if necessary Do you feel this former employer would rehire you? If you explain below; continue on Yes No answered “No” page twenty-nine (29) if necessary. name (first name, last name) title Supervisor’s Supervisor’s Telephone number where your former supervisor may be reached and time available to take calls Daytime Evening Telephone number ( ) Best time to call: Area code (work or cell phone) Yes No Did you ever received or do you have any pending disciplinary actions? Explain below; continue on twenty-nine (29) if necessary. Co-worker’s name: (first name, last name) Telephone number where co-worker can be reached ( ) Best time to call: Daytime Evening Area code (home or cell phone) initials Investigator’s
Print clearly and use black ink only 4th former employer or period of unemployment Investigator’s initials Name of former employer Former employer’s mailing address Start Date Month / Year End Date Month / Year Full time Part-Time Temporary Military Self-Employed Volunteer Internship Unemployed Former employer’s telephone number for employment verification (Personnel) Your title or position Telephone number ( Area code ) Reason for leaving employment Resigned to take better position Lay off Contract expired Return to school Terminated (fired) Completion of military service Resigned to avoid being terminated Resigned while under investigation Quit without giving notice as required by company policy Reason not listed, explain below Explain reason for leaving employment; continue on page twenty-nine (29) if necessary Do you feel this former employer would rehire you? If you answered “No” explain below; continue on page twenty-nine (29) if necessary. Yes No Supervisor’s name (first name, last name) Supervisor’s title Telephone number where your former supervisor may be reached and time available to take calls Telephone number ( Area code ) (work or cell phone) Best time to call: Daytime Evening Did you ever received or do you have any pending disciplinary actions? Explain below; continue on twenty-nine (29) if necessary. Yes No Co-worker’s name: (first name, last name) Telephone number where co-worker can be reached ( ) Area code (home or cell phone) Best time to call: Daytime Evening Investigator’s initials