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Fairfax County Public Schools Department of Human Resources 8115 Gatehouse Road Falls Church Virginia 22042 AN EQUAL OPPORTUNITY EMPLOYER EMPLOYMENT REFERENCE PART I TO BE COMPLETED BY APPLICANT I am applying for a position as at with Fairfax County Public Schools. Please complete the appropriate evaluation categories that apply to your knowledge of my background and mail to the Department of Human Resources. Applicant s Name I give permission for information pertaining to my work experience to be released to Fairfax County Public Schools and I release the evaluator and Fairfax County Public Schools from liability for using that information* I understand that the evaluator will be providing this information on a confidential basis to Fairfax County Public Schools and not to me and I waive any right that I may have to review this release. Signature of Applicant Date Type of Position Held by Applicant Date of Service From Mo. /Yr. To Mo. /Yr. Length of Service Reason for Leaving CATEGORY check column Superior Above Average KNOWLEDGE PERFORMANCE WORK HABITS ABILITY TO WORK WITH OTHERS PERSONAL QUALITIES COMMUNICATION SKILLS OVERALL RATINGS COMMENTS Would you rehire or employ this applicant Yes No If no please explain Relationship to the Applicant supervisor co-worker etc* Name of Person Completing Form please print Business Name and Address please print Business Telephone Number area code and number Signature HR 125 5/06 Date Below Unacceptable. Please complete the appropriate evaluation categories that apply to your knowledge of my background and mail to the Department of Human Resources. Applicant s Name I give permission for information pertaining to my work experience to be released to Fairfax County Public Schools and I release the evaluator and Fairfax County Public Schools from liability for using that information* I understand that the evaluator will be providing this information on a confidential basis to Fairfax County Public Schools and not to me and I waive any right that I may have to review this release. Applicant s Name I give permission for information pertaining to my work experience to be released to Fairfax County Public Schools and I release the evaluator and Fairfax County Public Schools from liability for using that information* I understand that the evaluator will be providing this information on a confidential basis to Fairfax County Public Schools and not to me and I waive any right that I may have to review this release. Signature of Applicant Date Type of Position Held by Applicant Date of Service From Mo. /Yr. To Mo. Signature of Applicant Date Type of Position Held by Applicant Date of Service From Mo. /Yr. To Mo. /Yr. Length of Service Reason for Leaving CATEGORY check column Superior Above Average KNOWLEDGE PERFORMANCE WORK HABITS ABILITY TO WORK WITH OTHERS PERSONAL QUALITIES COMMUNICATION SKILLS OVERALL RATINGS COMMENTS Would you rehire or employ this applicant Yes No If no please explain Relationship to the Applicant supervisor co-worker etc* Name of Person Completing Form please print Business Name and Address please print Business Telephone Number area code and number Signature HR 125 5/06 Date Below Unacceptable.

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