Housekeeping Reference

Thank you for providing feedback as part of our candidate evaluation process.

Applicant Info
Applicant's Name*
First Last
Your Info
Your Name*
First Last
Your Email*
Your Phone*
Employment Info
To the best of your recollection, what were the dates of the applicant's employment?
Begin Date (Month/Year - 00/00)*
End Date (Month/Year - 00/00)*

Please note if applicant is currently employed.
Job title and description of duties*
On a scale of 1-10 (10 being the best), please rate the applicant in the following areas:
And per our agency requirements, we need to verify that you are not related to her/him?
Trustworthy*
If 6 or below, please explain.
Proactive/Shows Initiative*
If 6 or below, please explain.
Professionalism*
If 6 or below, please explain.
Judgment/Common Sense*
If 6 or below, please explain.
Communication Skills*
If 6 or below, please explain.
Attention to Detail*
If 6 or below, please explain.
Dependable/Punctual*
If 6 or below, please explain.
Flexible/Cooperative/Takes Direction Well*
If 6 or below, please explain.
Energy/Stamina in the Position*
If 6 or below, please explain.
What is the square footage of the home(s) that she/he cleaned?*
How many hours per week did she/he work for you?*
Please describe the applicant’s strengths:*
Are there any areas that might need improvement?*
Why did the employment end?*

Please note if applicant is still employed.
Can you recommend this applicant without any reservation for this type of work?*
- Yes
- No
If no, why?
Do we have your permission to release this reference to potential household employers?*
- Yes - Share for Employment Reasons
- Yes - Share without my Personal Information
- Do not share (may preclude them from getting a job)
Do future employers have permission to contact you in reference to applicant?*
- Yes
- No

Housekeeping Reference

Applicant Info

Your Info

Employment Info