Employment Reference Applicant NamePosition Applied ForType of referenceEmploymentProfessionalPersonalSchoolLength of time employed Date Format: MM slash DD slash YYYY Start Date Format: MM slash DD slash YYYY EndEligible for rehireYesNoLength of time you have known the applicantProvide information about the applicant in the following areas by selecting the option you feel best answers the area. These questions are required by the Municipality of Anchorage Child and Adult Care Licensing Code for qualifications of caregivers. Please answer these questions to the best of your ability.Does the applicant show any serious health, alcohol, or drug problems? If yes, explain in commentsYesNoCommentsCan you attest to the applicant’s ability to work successfully with children? If no, explain in commentsYesNoCommentsIf you have never observed this person with children, do you believe this person has the ability to work successfully with children? If no, explain in commentsYesNoCommentsDoes the applicant show warmth, love, and acceptance of children?YesNoCommentsDoes the applicant give firm but fair discipline to children?YesNoCommentsTo your knowledge, has this person ever abused or neglected a child, committed a crime of violence, sexual assault, perjury or disorderly conduct?YesNoCommentsWhat qualities or skills do you believe will enable the applicant to work successfully or unsuccessfully with children:If you had a child that was in need of childcare, how would you feel about leaving the child in care with the person named above?Very goodGoodHesitantI would not leave my child in their careProvide information about the applicant in the following areas.Attendance/DependabilitySelect...Above AverageAverageBelow AverateCommunication (verbal and written)Select...Above AverageAverageBelow AverateInteractions with adultsSelect...Above AverageAverageBelow AverateOrganizational skills and abilitiesSelect...Above AverageAverageBelow AverateAny additional commentsYour Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Your PhoneMay we share this reference with the applicant?YesNoBy typing my name in the field below, I certify that the information provided contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge.SignaturePlease type your first and last name.CAPTCHA
