North Carolina A&T State University
Division of Human Resources
REFERENCE CHECK FORM
(5-14-2019) Equal Opportunity Employer Page 1 of 2
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:
Applicant’s Name:
First
Middle
Last
REQUESTING AGENCY INFORMATION: (To be completed by the hiring department)
Date of Request:
Name of Hiring Department:
Department Address:
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:
Phone
Number:
Mail
Address:
Date Completed:
Name of Employer:
Representative’s Name:
Representative’s Title:
Representative’s Phone:
If requested by Mail, please return to the Hiring Department’s address listed above.
North Carolina A&T State University
Division of Human Resources
REFERENCE CHECK FORM
(5-14-2019) Equal Opportunity Employer Page 2 of 2
APPLICANT INFORMATION:
Applicant’s Name:
First
Middle
Last
Employment Dates:
From:
To:
Reason for Leaving:
Major Job Duties:
Special Skills:
Met job requirements in terms of quantity of work? Exceeded Requirements
Met Requirements
Did Not Meet Requirements
Met job requirements in terms of quality of work? Exceeded Requirements
Met Requirements
Did Not Meet Requirements
Cooperated with fellow employees and supervisors?
YES NO
Usually came to work on time?
YES NO
Absent more than 10 days (except vacation) in the last
year of employment?
YES NO
If Yes, please explain:
Received an oral or written warning for performance or
conduct in the last year of employment?
YES NO
If Yes, please explain:
Committed any serious misconduct while on the job?
YES NO
If Yes, please explain:
Required close supervision?
YES NO
If Yes, please explain:
Would you rehire (or retain) this person? YES NO
If No, why?
Additional Comments/Explanations:
