Arizona State Personnel System
PRE-EMPLOYMENT VERIFICATION AND REFERENCE CHECK FORM
See ASPS/HRD-PA3.03, Application for Employment; Pre-employment Reference and Background Check policy for instructions and additional clarification.
Hiring agencies shall verify a candidate's most recent 5-year work history. Do not conduct a pre-employment check without a completed and
signed Application for Employment form from the respective candidate confirming you may contact the current and/or previous employers.
Candidate
Name
Being Considered for
(Job Title)
Section A (Employment History and Reference Checks)
Note: Make a copy of this section if more than one reference is required
Current State Employee?
Last Rate of Pay
YesNo
Briefly describe the duties and responsibilities the candidate is/was responsible for.
ASPS/HRD FA3.13 02/18 Page 1
Job ID #
HR RepWork Nbr./Equiv. Other
If yes, EIN
If additional space is needed, document below or on Page 2 under the Additional Comments Section
What do you believe are the candidate's strengths and skills?
Ability to work well with coworkers, subordinates (if applicable), supervisors/management?
Attendance, punctuality, and reliability? Capacity for discretion, good judgment, decision making and problem solving?
Immediate Spv.
Date of Contact
Confirm Candidate's
Dates of Employment
Were/are they in a supervisory/management role? If yes, how would you characterize their supervisory/management skills?
Were/are there any behavioral or performance issues or any areas of development or coaching needed? If yes, what are they?
Is there any other pertinent performance information about this candidate that we should consider?
Would you rehire this candidate into your organization?
If no, why not?
Additional Comments:
No Yes
How would you describe the candidates:
Person Contacted and Position Title
Phone Number
Organization Name & Location
Candidate's Job Title
Reason for ending employment
