Dear

The person identified below is being considered for
employment and has signed a statement authorizing this
verification and investigation.  We shall appreciate a
statement of your opinions and experiences as outlined
below.  Your reply will be considered confidential.


___________________________________
     Name of Applicant

___________________________________
     Social Security Number

___________________________________
     Dates of Claimed Employment

___________________________________
     Position Last Held

___________________________________
     Final Rate of Pay

Is the above information correct?  Yes______ No________
If not please make corrections.

What is your opinion as to this person's

Ability________________________Effort_________________________

Conduct________________________Attendance_____________________

Reason for leaving your employ________________________________
______________________________________________________________

Eligible for rehire?  Yes_____No_____If not, why?_____________
______________________________________________________________

Your further comments on any personal or professional strength
and weaknesses will be appreciated.___________________________
______________________________________________________________
______________________________________________________________

Date__________Signed_____________________Title________________