ࡱ> lnk[ |^bjbj  1fpa!\pa!\NN8<N".(-D!!!!!!!$#&!!w"l!l!l!^!l!!l!l!l!Ч CFl!!"0"l!'d'l!'l!Dq0"l!qqq!!~qqq"'qqqqqqqqqN> : 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 recommended. Per the attestation section on the 鶹 Pembroke application, the applicant certifies that he/she has given true, accurate and complete information in their application, any response(s) to supplemental questions, and/or in any information contained in their attached Curriculum Vitae/Resume and other documents, to the best of their knowledge. In the event confirmation or additional information is needed in connection with their application or work history, he/she authorizes educational institutions, associations, registration and licensing boards, former employers and others to furnish whatever detail is available concerning their qualifications and work history to the University of North Carolina at Pembroke. He/she understands that electronic submission of their application indicates his/her consent to the University's verification of any information contained in their application. He/she authorizes investigation of all statements made in the application and understands that false information or documentation, or a failure to disclose relevant information, may be grounds for rejection of the application, disciplinary action or dismissal shall be mandatory if fraudulent disclosures are given to meet position qualifications. (Authority: N.C.G.S. 126-30, N.C.G.S. 14-122-1). REFERENCE INFORMATION BEING REQUESTED ON:Applicant s Name:FirstMiddleLast REQUESTING DEPARTMENT INFORMATION: (To be completed by the hiring department)Date of Request:Name of Hiring Department:Department Address: FORMTEXT      Representatives Name:Representatives Title:Representatives 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 RequirementsMet job requirements in terms of quality of work? FORMCHECKBOX  Exceeded Requirements  FORMCHECKBOX  Met Requirements  FORMCHECKBOX  Did Not Meet RequirementsCooperated 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? 02`(*?ABCZ  024VXlnpz|϶ݫ϶ݠݕ϶݊϶jhUjhUjhUjhUjhUmHnHujhUjhU hCJh h56 h5 h6 hs6hshs66 24XZ\^7kd$$Ifl40*0*4 lalf4$If @]gds^`bn|$IfmkdV$$Ifl\ @0* @ P 4 lal*,NH; @@@$If7kdN$$Ifl40*0*4 lalf4$If $ @]a$kkd$$Ifl\ @0* @ P 4 lalNPR\Gkd$$Ifl0 0* 4 lal @@@$IfGkd$$Ifl0 0* 4 lal$If  \GkdP$$Ifl0 0* 4 lal$If @@@$IfGkdn$$Ifl0 0* 4 lal  #$%=>bGkd($$Ifl0 0* 4 lal @@@$IfGkd$$Ifl0 0* 4 lal>?@ABCj5kd$$Ifl40*0*4 lalf4$If$ @$If]a$Gkd$$Ifl0 0* 4 lalB~MGG$If]kd$$Ifl4Fx0*xFr    4 lalf4 @@@$If v@@@@$If7kdR$$Ifl40*0*4 lalf4~FGkd`$$Ifl0 0* 4 lal$If @@@$If]kdz$$Ifl4Fx0*xFr    4 lalf4FH\^`jl &**,@BDNPRThjlvxz|j hUj hU h5 hO^5 hO^6 h6hO^j` hUj~ hUj hUjhUmHnHujhUjhUh3Fnp\Gkd $$Ifl0 0* 4 lal$If @@@$IfGkd2 $$Ifl0 0* 4 lal"$&(*b```ZZZ$IfGkd $$Ifl0 0* 4 lal @@@$IfGkd $$Ifl0 0* 4 lal *RzIrkd $$Ifl\ @0* @ P 4 lal$If<kdB $$Ifl40*0*4 lalf4 ",.BDFPR~,.0:< ھڳڨڝژڍj"hU h>*j:hUj`hUjxhUj`hUjhU hCJhjhUmHnHujhUj hU3$,Tpkd|$$Ifl\ @0* @ P 4 lal$IfTV~yss$Ifkd$$Iflr p0* `` `` 4 lal>YOkd$$Ifl40 0* 4 lalf4$IfOkd$$Ifl40 0* 4 lalf4>@KL~NMkd~$$Ifl400*4 lalf4 x$Ifgd x$IfOkd$$Ifl40 0* 4 lalf4    ./0mt~)*89:FGUVWz{HHH~jhUUj$hUjhUjhUjrhUjhUj>hUjhU h>*j hUhjhUjhU1)[\z[OkdZ$$Ifl400*4 lalf4$IfMkd&$$Ifl400*4 lalf4bHdHfHHYSS$IfMkd$$Ifl400*`4 lalf4x$IfOkd$$Ifl400*4 lalf4 FORMCHECKBOX  YES  FORMCHECKBOX  NOIf Yes, please explain:  FORMTEXT      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      Has this employee ever committed workplace harassment? FORMCHECKBOXH H8H:HVHXHZHHHHHHHH~IIIIIIIIIIIIJ J4J6J8JBJDJJJJJJJJJJJJ K KKLKNKbKdKfKpK˦j+hUjfhUjhUh j)hUjdhUjhUhO^jhUmHnHuj'hUjbhUhjhU4HHIIIIFJYSS$IfMkd$$Ifl400*`4 lalf4x$IfOkd$$Ifl4 00* 4 lalf4FJHJJJKKKC=$IfMkd$$Ifl400*`4 lalf4x$If x$IfgdO^ x$Ifgd Okd$$Ifl4 00* 4 lalf4pKrKtKxKKKKKKKK L LLLLNLbLdLfLpLrLLLLLLMM"M$M&MLMNMbMdMfMpMrMvMMMN\\\\\ \<\>\@\jx#hO^Uj#hO^UUjhO^Uj3"hUjj!hUj hUjhUmHnHuj- hUjhhUjhUhO^hjhU2KtKvKxKzKKLLLtLSMkd$$Ifl400*`4 lalf4x$IfOkd$$Ifl4 00* 4 lalf4$If tLvLL.M0M2MtMWQQ$IfOkd!$$Ifl400*`4 lalf4x$IfOkd $$Ifl4 00* 4 lalf4tMvMMH\J\L\\PGG $IfgdO^Pkd#$$Ifl400*`4 lalf4ytG x$IfgdO^Rkd"$$Ifl400* 4 lalf4ytO^  YES  FORMCHECKBOX  NOIf Yes, please explain:  FORMTEXT       Additional Comments/Explanations:  FORMTEXT           The University of North Carolina at Pembroke Human Resources REFERENCE CHECK FORM Rev. 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ChavesOh+'0 $0 P \ h tReference CheckHuman Resources form1201Debbie E. Chaves2Microsoft Office Word@@r᛽@?>@?>w՜.+,0 hp  鶹-Chapel Hill Reference Check Title  !"#$%&'()*+,-./012356789:;<=>?@ABCDEFHIJKLMNOPQRSTUVWXYZ\]^_`abdefghijmRoot Entry FCoData 4%1TableG'WordDocument1fSummaryInformation([DocumentSummaryInformation8cCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q