Employment Referral Information Form

Employer:
Person Referrals should be made to:
Telephone:	i.e. xxx-xxx-xxxx
Email:
Preferred method of contact:	Phone Email
Number of open positions:
Position:
Start date:
Rate of pay:
Benefits:	Yes No
If yes, what type:
Opportunity for advancement:	Yes No
Work address:
City:	(Helps determine transportation needs for employee)
Probable Word Schedule:	Day Evening Overnight Split shift Seasonal (Please check all that apply)
Typical hours:
Typical days:
Requirements:	Valid driver's license Able to lift ... pounds Forklift training/exp. OSHA Other
If you checked Able to lift - how many pounds?:	(How many pounds required to lift, how often, etc.)
Other requirements:
Skills Necessary/Preferences:	(bilingual, customer service experience, landscaping experience, etc.)
Other Information that will help us connect you to potential employee:	(must travel, no theft convictions, etc.)
Security code:	Enter security code:

Completing this form does not bind employer to receive any/all employee referrals from MCC 180 RAP.