REFERENCE /BACKGROUND CHECK FOR EMPLOYMENT
APPLICANT: _____________________ POSITION: _____________________ To Whom It May Concern: The applicant named above is being considered for employment with Lander County School District. To help the District evaluate the applicant’s qualifications, please answer the employment questions listed on page two (2) . Thank you.
Sallie Snapp Payroll/Personnel
APPLICANT’S AUTHORIZATION
My signature below authorizes the school district to conduct a background investigation and authorizes release of information in connection with my application for employment. This investigation may include such information as criminal or civil convictions, driving records, previous employers and educational institutions, personal references, professional references, and other appropriate sources. I waive my right of access to any such information, and without limitations hereby release the school district and the reference source from any liability in connection with its release or use. This release includes the sources cited above and specific examples as follows: the local Sheriff, information from the Central Criminal Records Exchange of either date on all criminal convictions of certification that no date on criminal convictions are maintained, information from the State Department of Social Services Child Protective Services Unit and any Locality to which they may refer for release of information pertaining to any findings of child abuse or neglect investigations involving me.
_____________________________________________ Applicant’s Signature Date
Page 1 of 2
Reference Check Page 2 of 2
RE:_____________________________
Employment Date:
From:_______________
To:________________
Position/Job Duties:____________________________________________ ____________________________________________ Attendance Record:_____________________________________________ Reason(s) for Leaving:_____________________________________________________ Please evaluate the applicant regarding their quality of work and ability to get along with other employees:__________________________________________________________ __________________________________________________________ __________________________________________________________ Would you rehire this applicant? Do you recommend employment? Yes______ Yes______ No______ No______
___________________________ Organization
________________________________ Representative’s Name and Title
________ Date