Request for Employment Information


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Applicant:_____________________________
Social Security Number:_________________

Name of Company:___________________________________________

Company Address:____________________________________________

Company Phone Number:____________________________________________

Supervisor's Name:______________________________________________

Dates of Employment: From:_________To:__________

I, _______________________, having made application with Building Blocks Unlimited D.B.A. Labor Exchange Division, I hereby authorize the release of information directly to said company. I release and hold harmless present and past employers, references and all persons and institutions whomsoever, from any charge because of furnishing this information. I waive any application to the Family Education Rights and Privacy Act insofar as the same might apply to responding to this request for this information.

Signature of Applicant:_______________________ Date:___________

BUILDING BLOCKS UNLIMITED P.O. BOX 30851 FLAGSTAFF, AZ 86003-0851

To prior employer: Your assistance with feedback about the following applicant's work habits and behaviors would be greatly appreciated.

How would you rate the applicant in the following areas:

1=Excellent 2=Good 3=Fair 4=Poor

____ Ability to work with supervisor(s).
____ Ability to work with co-worker(s).
____ Ability to understand and follow directions.
____ Ability to take oral direction.
____ Ability to comprehend written direction.
____ "Work ethic".
____ Ability to persevere.
____ Safety habits.
____ Ability to complete work assignments.
____ Dependability.
____ Promptness.
____ Ability to supervise.
____ Ability to interact with the public.
____ Personal work habits.
____ Driving skills.
____ Ability to ask for help.

Additional Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Company Representative:

__________________________
Signature

__________________________
Title

BUILDING BLOCKS UNLIMITED P.O. BOX 30851 FLAGSTAFF, AZ 86003-0851


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