M & M HOME CARE EMPLOYMENT REFERENCE CHECK

M & M HOME CARE EMPLOYMENT REFERENCE CHECK
PART I – COMPLETED BY APPLICANT

By signing this release, I am voluntarily requesting that your Company depart from the general policy in responding to reference requests from any prospective employer that may be considering me for employment.

I authorize your Company to disclose to such prospective employers any employment-related information that the Company, in its sole discretion and judgment, may determine is appropriate to disclose, including any personal comments, evaluations, or assessments that may have about my performance or behavior as an employee.

In exchange for your Company’s agreement to depart from its general policy and to disclose additional employment-related information pursuant to my request, I agree to release and discharge the Company and the Company's successors, employees, officers, and directors for all claims, liabilities, and causes of action, know or unknown, fixed or contingent, that arise from or that are in any manner connected to your Company’s disclosure of employment-related information to prospective employers. This release includes, but is not limited to, claims of defamation, libel, slander, negligence, or interference with contract or profession.

I acknowledge that I have carefully read and fully understand the provisions of this release. I further acknowledge that I was given the opportunity to consult with an attorney or any other individual of my choosing before signing this release and that I have decided to sign this release voluntarily and without coercion or duress by any person.
Applicant Name Applicant Name First Last
Last Four Digits of Social Security Number
Must be 4 characters. Currently Entered: 0 characters.
Name of Employer
Name of Supervisor
Contact Number of Supervisor
Supervisor Email
Fax Number
Position Held
Start Date of Employment Start Date of Employment / MM / DD YYYY
End Date of Employment End Date of Employment / MM / DD YYYY
ELECTRONIC SIGNATURE
By selecting the "SUBMIT" button, you are signing this Agreement electronically. You agree your electronic signature (hereafter referred to as your "E-Signature") is the legal equivalent of your manual/handwritten signature on this Agreement.

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.

Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
DATE SIGNED DATE SIGNED / MM / DD YYYY
PART II – COMPLETED BY EMPLOYER

Please find the applicants signed consent form releasing prior employers to provide our organization information on [his/her] employment history, salary and performance. We appreciate your time and attention to this matter.
POSITION HELD: _____________________________________________________
EMPLOYMENT START: ____ / ____ /____ EMPLOYMENT END: ____ / ____ /____
WORK ATTITUDE: ___ ACCEPTABLE ___ UNACCEPTABLE ___N/A
ATTENDANCE: ___ ACCEPTABLE ___ UNACCEPTABLE ___N/A
DEPENDABILITY: ___ ACCEPTABLE ___ UNACCEPTABLE ___N/A
RELATIONSHIPS WITH CO-WORKERS: ___ ACCEPTABLE ___ UNACCEPTABLE ___N/A
OVERALL ASSESSMENT: ___ ACCEPTABLE ___ UNACCEPTABLE ___N/A
WOULD YOU RE-HIRE THIS INDIVIDUAL?: ___ YES ___ NO
COMMENTS: _________________________________________________________________
PERSON COMPLETING THIS FORM: ______________________________________ TITLE : _______________________
DATE: ____ / ____ /____
THANK YOU

If you have any questions, please contact M & M Home Care at 248.599.2410 or email us at HR@MMHomeCare.com.