Employment Form

* = Required Information

Last Name: *

First Name: *

Middle Initial: *

Social Security #:

Position Held:

Employed From:

To:

Company Name:

Telephone #:

Address:*

City: *

State:

Zip: *

Supervisor's Name:

Title:

Position applying for with SSHCR:

I have applied for a position with SSHCR, and desire you to share my work record with them.I hereby release you and your company from anay and all liability for providing the information listed below. My name was_____________________while in your employment.

Applicant's Signature

(checking the checkbox above is equivalent to handwritten signature)

Please complete the following:

Professional References

Personal Reference

Dates of employment:

Hire Date:

Term Date:

Would you Re-Hire?

Yes

Do you have any furthere information you would like for us to consider regarding this applicant?

Compeleted By:

Title:

Date:

For Solid Source Human Resources use only if statement is taken via Phone

Spoke With:

Title:

HR Representative:

Date:

Time: