Employment Verification Form

Employment Verification Form

St. Petersburg College - Office of Human Resources

The applicant below is being considered for employment at St. Petersburg College. The College requests your assistance

in helping us select a reliable, qualified candidate with valuable work experience. Your prompt response is appreciated.

Thank you in advance for your cooperation.

Section 1: APPLICANT COMPLETES

I authorize St. Petersburg College to obtain employment verification information as requested below, and I release all such parties from all liability for any damage that may result from furnishing such information.

__________________________________ ______________________________/________ _________________

Applicant’s printed name Applicant’s signature /Date Social Security Number

Employer Information:

_____________________________________________________________________ Fax:_______________________________

_____________________________________________________________________ (Providing a fax # will expedite hiring process.)

_____________________________________________________________________ Phone: ____________________________

Is this applicant’s current employer? o Yes o No

If yes, check one: o SPC may contact applicant’s current employer at this time.

o SPC may not contact applicant’s current employer until hired by St. Petersburg College.

Job title / Duties:__________________________________________________________________________________________________

Employment dates: From: ______/______ /______ To:______ /______ /______

Status: o Full-time o Part-time o Temporary/Other

Eligible for rehire? o Yes o No Comments:_______________________________________________________________________

Reason for Leaving:_______________________________________________________________________________________________

Were any allegations of sexual harassment, workplace violence or other acts of illegal discrimination against you validated during your employment? o No o Yes (explain)_______________________________________________________________________

______________________________________________________________________________________________________________

On a scale of 1-5, how would you rate your work performance for this employer?

o 5 - Outstanding o 4 - Above Satisfactory o 3 - Satisfactory o 2 - Needed Improvement o 1 - Unsatisfactory

Comments:_____________________________________________________________________________________________________

Section 2 - FORMER EMPLOYER COMPLETES (and returns to St. Petersburg College):
Is the information provided above accurate? o Yes o No

If no, please provide accurate information:__________________________________________________________________________

Do you agree with the applicant’s rating of his/her work performance? o Yes o No

Comments:_________________________________________________________________________________________________

___________________________________________________________________________________________

Are you aware of any information that may affect his/her ability to work effectively? o Yes o No

Comments:_________________________________________________________________________________________________

___________________________________________________________________________________________

______________________________         __________________________/________      ____________________

Printed name of person completing this form                 Signature                                       /    Date                            Title

NOTE: AFTER COMPLETING, PLEASE RETURN PROMPTLY TO ST. PETERSBURG COLLEGE:

By fax (preferred): (727)______________________          OR By mail: Human Resources, SPC, PO Box 13489 St. Petersburg, FL 33733

HR 410 (12/03)                                                 St. Petersburg College is an Equal Access/Equal Opportunity institution.