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EMPLOYMENT REFERENCE CHECK FOR MANAGEMENT POSITION Candidate name Date Company Contact Number Name & Title of person...

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Contact Number

Name & Title of person being contacted Capacity of relationship, i.e. supervisor, co-worker, etc. (Candidate name) is being considered for employment with Ageia Health Services as a S/he has indicated you as a person/company who may be able to give us some insight into her/his skills, abilities, and work habits. We are hoping you will support us in making an important hiring decision. This candidate has signed for release of reference information asked below (see signature page if applicable). 1. Dates of employment:


2. Beginning position:


3. Beginning wage


4. How long have you worked with/known the candidate? 5. Please outline his/her position and main responsibilities.

6. Please describe the quality and accuracy of his/her work.

7. What do you consider to be the candidate's key strengths?

8. What would you consider to be his/her areas for improvement?

9. If candidate was responsible for managing budgets or monies, how did s/he perform?

10. Would you describe her/him as a leader or follower and why?

11. How would you describe the candidate's attendance, punctuality and reliability?

12. What is your experience of the candidate's honesty and integrity?

13. Can he/she handle pressure? Can you support this with an example?

14. Did s/he receive any counseling or disciplinary action during their employment (what for)?

15. Can you describe how s/he maintained their immediate work area or office?

16. Would you comment on his/her attention to detail?

17. Provide examples of his/her ability to handle upset or angry customers.

18. Please describe her/his abilities or skills in the following areas: a. Operate and maintain office equipment:

b. Telephone etiquette/oral communication

c. Writing ability

d. Giving/following directions

e. Computer/software skills

19. How would you describe the candidate's energy level and stamina?

20. What would you say was his/her biggest accomplishment while working at your company?

21. Why did the candidate leave your company?

22. Theoretically, would you re-employ him/her?

23. Is there anything else you would like to add about this candidate?

Reference information release I hereby allow

to provide Ageia Health Services and its entities with any

requested information asked above for my length of employment. I hereby release from any legal responsibility. Candidate Signature:

Reference done by: