Reference Form

Name of Applicant :

*

Your Name :

*

Company/Organization:

Position:

Work Phone # (For Verification)  

*

Cell Phone:

Best Time To Call

*

What is your connection to the applicant?

How long have you known the applicant?

If you prefer talking by telephone about this candidate concerning his/her performance record, please call our office at 845-947-3223

For the following 4 Questions, please choose the appropriate response.
On the following line, enter any additional comments that are needed for explaination.

Does the applicant accept extra duties willingly? :

Select Yes No

With your present knowledge, would you employ or re-employ this person?

Select Yes No

Is there any reason you would not want to see this person working with children?

Select Yes No

Please give your opinion of the applicant’s skills in activities, or work situations,
at which you believe he/she is best.

To your knowledge, has the applicant ever exhibited abuse or sexually improper
tendencies towards others? If so, please specify.

Would you want this person to be your child’s counselor? Why or Why not?

Judgment & Problem Solving

Communication

Work Ethic

Team Player

Flexible & Adaptable

Select Superior Above Average Average Below Average Unsatisfactory

Developing Relationships

Select Superior Above Average Average Below Average Unsatisfactory

Performs specific responsibilities

Select Superior Above Average Average Below Average Unsatisfactory

Maintains safety

Select Superior Above Average Average Below Average Unsatisfactory

Decision making ability

Please select your overall rating of this applicant