ࡱ> lnk` Jbjbj 1^x 8<(^(jH((((((($)h?,<(i<((###v(#(### P"HhZ ##d(0(#- P-#-#(>0"#8>>><(<(,#^>>>( Under North Carolina General Statute 126, pre-employment references solicited by the University are confidential and may not be released to the applicant, employee or public. Use of this form by departments is optional. When checking references by mail, attach a copy of the application signature showing the applicant's authorization to release information to the University. REFERENCE INFORMATION BEING REQUESTED ON:Applicants Name:FirstMiddleLast REQUESTING DEPARTMENT INFORMATION: (To be completed by the hiring department)Date of Request:Name of Hiring Department:Department Address: FORMTEXT      Representative s Name:Representative s Title:Representative s Phone: EMPLOYER INFORMATION: (To be completed by previous/current employer if by mail; or by hiring department if by phone)This reference information furnished by:X Phone Number:  FORMTEXT       FORMCHECKBOX  MailAddress:  FORMTEXT      Date Completed: FORMTEXT      Name of Employer: FORMTEXT      Representative s Name: FORMTEXT      Representative s Title: FORMTEXT      Representative s Phone: FORMTEXT       If requested by Mail, please return to the Hiring Department s address listed above. APPLICANT INFORMATION:Applicant s Name: FORMTEXT       FORMTEXT       FORMTEXT      FirstMiddleLastEmployment Dates:From: FORMTEXT      To: FORMTEXT      Reason for Leaving: FORMTEXT      Major Job Duties: FORMTEXT      Special Skills: FORMTEXT      Met job requirements in terms of quantity of work? FORMCHECKBOX  Exceeded Requirements  FORMCHECKBOX  Met Requirements  FORMCHECKBOX  Did Not Meet Requirements Met job requirements in terms of quality of work? FORMCHECKBOX  Exceeded Requirements  FORMCHECKBOX  Met Requirements  FORMCHECKBOX  Did Not Meet Requirements Cooperated with fellow employees and supervisors? FORMCHECKBOX  YES  FORMCHECKBOX  NOUsually came to work on time? FORMCHECKBOX  YES  FORMCHECKBOX  NOAbsent more than 10 days (except vacation) in the last year of employment? FORMCHECKBOX  YES  FORMCHECKBOX  NOIf Yes, please explain:  FORMTEXT { | B D     * , 2 4 P R T v x $&(j hUjhUjhUjxhUjxhUjhUmHnHujZhUjhU hCJ h56 h5 h6h7{ | 7kd$$Ifl40*0*4 lalf4$If $ @]a$,IJ $Ifmkd^$$Ifl\ @0* @ P 4 lal D F h H; @@@$If7kd$$Ifl40*0*4 lalf4$If $ @]a$kkd$$Ifl\ @0* @ P 4 lalh j l \Gkdb$$Ifl0 0* 4 lal @@@$IfGkd$$Ifl0 0* 4 lal$If , . \Gkd$$Ifl0 0* 4 lal$If @@@$IfGkd$$Ifl0 0* 4 lal. 0 ` b d bGkd$$Ifl0 0* 4 lal @@@$IfGkdL$$Ifl0 0* 4 lal j5kd$$Ifl40*0*4 lalf4$If$ @$If]a$GkdD$$Ifl0 0* 4 lal . 0 2 b MGG$If]kd$$Ifl4Fx0*xFr    4 lalf4 @@@$If v@@@@$If7kd$$Ifl40*0*4 lalf4 6FGkd` $$Ifl0 0* 4 lal$If @@@$If]kdb$$Ifl4Fx0*xFr    4 lalf4(24fh|~024>@F FH\^`jlnp.溵 hCJjhUjdhUj hU h5 hCJ h6j hUj hUj hUhjhUjhUmHnHu668f\Gkd2 $$Ifl0 0* 4 lal$If @@@$IfGkdB $$Ifl0 0* 4 lalBDF b``Z$IfGkd $$Ifl0 0* 4 lal @@@$IfGkd$ $$Ifl0 0* 4 lal "FnSmkdL$$Ifl\ @0* @ P 4 lal$If7kd $$Ifl40*0*4 lalf4  @Hpkkd$$Ifl\ @0* @ P 4 lal$If.02<>HJ^`bln 24HJLVX024Z\xz| ڹڮکڞړڈکjhUjhUjhU h>*jhUj0hUj8hUjhUhjhUmHnHujhUjhU5pr~xx-xJkd$$Ifl40 0* 4 lalf4$Ifkdl$$Iflr p0* `` `` 4 lal2Z\c[[x$IfJkd$$Ifl40 0* 4 lalf4Jkd$$Ifl40 0* 4 lalf4$If e__$IfHkd&$$Ifl400*4 lalf4x$IfHkdn$$Ifl400*4 lalf456DEFYZhij  '(678DUjghUjhUjhUjDhUjhUjhUjhUjhUj>hUjhUjhUh1 <=c[[x$IfJkd$$Ifl400*4 lalf4$IfJkdj$$Ifl400*4 lalf4DDD2Ee]]x$IfJkd$$Ifl4 00* 4 lalf4$IfHkd$$Ifl400*`4 lalf4     Received an oral or written warning for performance or conduct in the last year of employment? FORMCHECKBOX  YES  FORMCHECKBOX  NOIf Yes, please explain:  FORMTEXT      Committed any serious misconduct while on the job? FORMCHECKBOX  YES  FORMCHECKBOX  NOIf Yes, please explain:  FORMTEXT      Required close supervision? FORMCHECKBOX  YES  FORMCHECKBOX  NOIf Yes, please explain:  FORMTEXT      Would you rehire (or retain) this person? FORMCHECKBOX  YES  FORMCHECKBOX  NOIf No, why?  FORMTEXT      Additional Comments/Explanations:  FORMTEXT           The University of North Carolina at Pembroke Human Resources REFERENCE CHECK FORM Rev. 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