DEPARTMENT OF ECONOMIC OPPORTUNITY

REFERENCE CHECK AND EMPLOYMENT VERIFICATION

Organization Contacted	Phone Number
Person Contacted	Position
1.	gave your name as a current/former
employer. What were the dates of employment?
From	to	Hrs. per week
mo/day/yr
mo/day/yr
2.	What position was held? (a) at time of employment
(b) when applicant left
3.	Earnings $
4.	Supervisory duties?	If yes, how many supervised, and what were the duties?
5.	Work Rating: Quality of Work (accuracy, judgement, initiative, etc.)
6.	Applicant's main job responsibilities? (Duties for which the employee spent 50%or more time performing)
Other duties:
7.	How are these responsibilities considered by your organization?
Professional	Para Professional	Clerical
Professional-Administrative	Technical	Other
8.	Were any disciplinary actions taken against the applicant?	If yes, please explain
9.	Does/Did the applicant's absenteeism affect his/her performance or productivity of the unit?
If yes, please explain
10.	How well does/did the applicant get along with supervisor(s) and co-workers?
11.	Overall strong points
Overall weak points
Checked by:
Name	Title	Date	Phone #

DEO Form OPT-35 (2/01)

DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

J0JEM

1999-11-17

mcgillj

FDLES J&B OIT