Arizona State Personnel System
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.
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
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
ASPS/HRD FA3.13 02/18 Page 2
Section B (Degree, License or Certification)
Note: Optional, if not required for position. If more than two institutions/organizations are contacted, annotate below in Additional Comments.
Section C (Personnel File Review and Performance Appraisal Scores)
Note: This section is required if the candidate is a current or former Arizona State Personnel System Employee
Overall Score
Rating Period
Noteworthy comments
Noteworthy comments
Overall Score
Rating Period
If yes, date and type
If yes, date, action and reason for action
Disciplinary or Dismissal Actions
Date SPS Personnel File
Name/signature of
file reviewer
Additional Comments:
(Additional responses to questions, evaluation comments or attempts to demonstrate due diligence in obtaining reference checks)
Printed Name Date
Pre-employment Check Completed By
No Yes
No Yes
No Yes
Type of degree, license or certification
Name of School or credentialing organization
Is license or certification still in good standing?
Type of degree, license or certification
Name of School or credentialing organization
Is license or certification still in good standing?
Expiration date
Date information verified
Expiration date
Date information verified
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