Employment Verification Form

Bexar County Medical Society Staffing Services

6243 IH 10 west, Ste 625

San Antonio, Texas 78201

Phone: (210) 301-4362 Fax: (210) 301-2152

Please fill out the appropriate information below (list the most recent employer):

Name of Company Phone

Name of Your Supervisor

Full name used while employed at this company Social Security Number

Dates of Employment Position Held

PERMISSION FOR RELEASE OF INFORMATION

I understand that individuals or corporations may be contacted to provide information relating to my prior employment, education or

character, and I hereby release this information. I further authorized release of any and all information, including but not limited to my

credit history, motor vehicle driving records, criminal and civil records, prior employment (including contacting prior employers), education

(degree, GPA, and attendance) as well as other public record information to any prospective employer.

Signature of Applicant Date

(For Office Use Only)

The person listed above is applying for a position in a physician’s office and has listed you as a former employer.

We would appreciate it if you would take a few moments to provide us with the following information:

ARE THE DATES OF EMPLOYMENT LISTED ABOVE CORRECT? Yes No

IS THE TITLE OF POSITION HELD CORRECT? Yes No

If no, please comment:

Poor Fair Average Good Very Good Excellent

Performance

Attitude

Attendance

Staff Interaction

Would you consider this individual for rehire? Yes _____ No _____

If no, please comment:

Additional Comments:

____________________________

Signature and Title