Life's New Beginnings, Inc.

7031 Rockwood Drive

Port Richey, Fl . 34668

Phone: 727-841-7161 Fax: 727-841-7671

I, __________________________________________________________, have applied for a position with

(please print full name)

Life's New Beginnings as ______________________________________________________________.

Please complete and return the evaluation below. This is an authorization for you to release this information.

___________________	______________________________________

Date	Signature of Prospective Employee

Company Name_______________________________	Employment Dates___________to___________

Address_____________________________________	Job Title_______________________________

_____________________________________	SS#___________________________________

Att: _____________________________________

phone ______________________________________ fax___________________________________

Employer, our funding sources require this information be included in the employee's personnel file. Your immediate attention is appreciated. If the information above is incorrect, please enter correct information .

Employment Dates___________to____________ Job Title____________________________________

Major Duties____________________________________________________________________

Outstanding	Superior	Average	Fair	Unsatisfactory
Application of Knowledge
Quality of Work
Dependability
Supervisory Ability
Attendance
Ability to Work with Others

Reason for Leaving__________________________________________________________________________

Would you Rehire? Yes____ No____

Are you aware of any reason that might question this person's suitability for employment where he or she would come into contact with developmentally challenged individuals? Yes____ No____

Date________________

Completed By_______________________________________________ Title_______________________________