jobs.pwcs.edu
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204.122.110.95
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https://jobs.pwcs.edu/workspace/wFormEX.exe?LinkID=9nrmjddv2b5agm2n
Submission: On July 27 via manual from US — Scanned from DE
Submission: On July 27 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: FE_LINKREF_01 — POST wformio.exe?Action=Submit
<form name="FE_LINKREF_01" onsubmit="return preparesubmit(this);" method="post" action="wformio.exe?Action=Submit">
<input type="hidden" name="SSN" value="%%SSN%%">
<input type="hidden" name="FormVersion">
<table width="100%" cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td width="30%"> </td>
<td width="40%" align="center">
<font class="title">Prince William County Public Schools</font>
<br>
<font class="title">Pre-Employment Reference Check</font>
</td>
<td width="30%" align="right">
<font class="label">Ref #: </font>
<font class="entry">00818155</font>
</td>
</tr>
</tbody>
</table>
<br>
<font class="label">Instructions: Your name has been provided to assist in completing a background investigation to help us determine this person’s suitability for employment. Therefore, we ask that you complete all items on this form as soon as
possible so we can complete the process in a timely and efficient manner. PWCS keeps information confidential and does not share it with the candidate or other party unless release or disclosure is otherwise required by law or deemed necessary by
PWCS.</font>
<br>
<br>
<table class="section" width="100%" cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td>
<font class="section"><strong>APPLICANT</strong></font>
<a name="applicant"></a>
</td>
</tr>
</tbody>
</table>
<br>
<table width="100%" cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td>
<font class="label">Applicant Name: </font>
<font class="entry">Derya KOC</font>
</td>
<td>
<font class="label">PID: </font>
<font class="entry">310638</font>
</td>
</tr>
<tr>
<td colspan="2">
<font class="label">Positions Applied For: </font>
<font class="entry"> ADMINISTRATIVE ASSISTANT II - 223 DAYCENTRAL OFFICE FINANCE SPECIALIST II - 250 DAY - OPEN UNTIL FILLEDDATA CONTROL SPECIALIST II - 250 DAYOFFICE ASSISTANT - 195 DAYTEACHER ASSISTANT - 188 DAY </font>
</td>
</tr>
</tbody>
</table>
<table cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td>
<font class="label">Employment Confirmation </font>
</td>
</tr>
<tr>
<td>
<font class="label">Start Date: </font>
</td>
<td>
<font class="entry"><input type="text" name="EmpConfStartDate" size="10" maxlength="10"></font> <img src="images/calendar.gif" style="border:0; vertical-align:middle;"
onclick="showCalendar(this,document.forms[0].EmpConfStartDate, 'MM/DD/YYYY',null,1,-1,-1)"> (MM/DD/YYYY)
</td>
<td>
<font class="label"> End Date: </font>
</td>
<td>
<font class="entry"><input type="text" name="EmpConfEndDate" size="10" maxlength="10"></font> <img src="images/calendar.gif" style="border:0; vertical-align:middle;"
onclick="showCalendar(this,document.forms[0].EmpConfEndDate, 'MM/DD/YYYY',null,1,-1,-1)"> (MM/DD/YYYY)
</td>
</tr>
</tbody>
</table>
<br>
<table class="section" width="100%" cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td>
<font class="section"><strong>REFERENCE CONTACT</strong></font>
<a name="contact"></a>
</td>
</tr>
</tbody>
</table>
<br>
<table cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td valign="top">
<table cellpadding="1" cellspacing="1" width="100%">
<tbody>
<tr>
<td>
<font class="label">Contact Name: </font>
</td>
<td>
<font class="entry"><input type="text" name="RefFirstName" maxlength="18" value="BARIS"> <input type="text" name="RefMI" maxlength="1"> <input type="text" name="RefLastName" maxlength="24" value="ERKUS"></font>
</td>
</tr>
<tr>
<td>
<font class="label">Home Phone: </font>
</td>
<td>
<font class="entry"><input type="text" name="RefHomePhone"></font>
</td>
</tr>
<tr>
<td>
<font class="label">School Div. or Company: </font>
</td>
<td>
<font class="entry"><input type="text" name="RefCompany" maxlength="30" value="Ogis Chemicals, TURKEY"></font>
</td>
</tr>
</tbody>
</table>
</td>
<td>
<table cellpadding="1" cellspacing="1" width="100%">
<tbody>
<tr>
<td>
<font class="label"> Position:</font>
</td>
<td>
<font class="entry"><input type="text" name="EmpConfPos" maxlength="40"></font>
</td>
</tr>
<tr>
<td>
<font class="label"> Work Phone:</font>
</td>
<td>
<font class="entry"><input type="text" name="RefWorkPhone" maxlength="20" value="2163644400"></font>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td> </td>
</tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<table cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td>
<font class="label">Please indicate your relationship to this candidate </font>
</td>
<td>
<font class="entry"><select id="Relationship" name="Relationship" onchange="displayOtherRelationship();">
<script language="javascript">
pld_FE_REF_RELATIONSHIP("");
</script>
<option value="XXXNothingSelectedXXX"><No Selection></option>
<option value="Coworker/Peer">Coworker/Peer</option>
<option value="Department Chair/Team Lead">Department Chair/Team Lead</option>
<option value="Mentor">Mentor</option>
<option value="Other">Other</option>
<option value="Personal (Friend/Family)">Personal (Friend/Family)</option>
<option value="Professor">Professor</option>
<option value="Supervisor - Employment">Supervisor - Employment</option>
<option value="Supervisor – Volunteer Work">Supervisor – Volunteer Work </option>
</select> <img border="0" src="images/reqd.gif" alt="Required Field"></font>
</td>
</tr>
<tr id="OtherRow" style="display: none;">
<td>
<font class="label">Please provide what the relationship was: </font>
</td>
<td>
<font class="entry"><input id="OtherRelationship" name="OtherRelationship" size="40" maxlength="40"> <img border="0" src="images/reqd.gif" alt="Required Field"></font>
</td>
</tr>
</tbody>
</table>
<br>
<table class="section" width="100%" cellpadding="2" cellspacing="1">
<tbody>
<tr>
<td>
<font class="section"><strong>EVALUATION</strong></font>
<a name="evaluation"></a>
</td>
</tr>
</tbody>
</table>
<table cellpadding="1" cellspacing="1">
<tbody>
<tr>
<td colspan="2" valign="top">
<font class="label"> </font>
</td>
<td align="center" width="8%">
<font class="label">EXCELLENT</font>
</td>
<td align="center" width="8%">
<font class="label">GOOD</font>
</td>
<td align="center" width="8%">
<font class="label">FAIR</font>
</td>
<td align="center" width="8%">
<font class="label">POOR</font>
</td>
<td align="center" width="8%">
<font class="label">N/A</font>
</td>
</tr>
<tr class="lineB">
<td>
<font class="label"> </font>
</td>
<td colspan="6">
<font class="label">Relationships with: </font>
</td>
</tr>
<tr class="lineA">
<td>
<font class="label">1.</font>
</td>
<td>
<font class="label">(a) Staff </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ1" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ1" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ1" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ1" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ1" value="0"></font>
</td>
</tr>
<tr class="lineB">
<td>
<font class="label"> </font>
</td>
<td>
<font class="label">(b) Students </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ2" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ2" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ2" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ2" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ2" value="0"></font>
</td>
</tr>
<tr class="lineA">
<td class="list">
<font class="label"> </font>
</td>
<td>
<font class="label">(c) Parents </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ3" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ3" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ3" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ3" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ3" value="0"></font>
</td>
</tr>
<tr class="lineB">
<td>
<font class="label"> </font>
</td>
<td>
<font class="label">(d) Supervisor(s) </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ4" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ4" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ4" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ4" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ4" value="0"></font>
</td>
</tr>
<tr class="lineA">
<td>
<font class="label">2.</font>
</td>
<td>
<font class="label">General Behavior or Conduct </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ5" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ5" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ5" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ5" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ5" value="0"></font>
</td>
</tr>
<tr class="lineB">
<td>
<font class="label">3.</font>
</td>
<td>
<font class="label">Dependability & Attendance </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ6" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ6" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ6" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ6" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ6" value="0"></font>
</td>
</tr>
<tr class="lineA">
<td>
<font class="label">4.</font>
</td>
<td>
<font class="label">Attitude at Work </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ7" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ7" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ7" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ7" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ7" value="0"></font>
</td>
</tr>
<tr class="lineB">
<td>
<font class="label">5.</font>
</td>
<td>
<font class="label">Overall Job Performance </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ9" value="1"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ9" value="2"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ9" value="3"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ9" value="4"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ9" value="0"></font>
</td>
</tr>
</tbody>
</table>
<br>
<table>
<tbody>
<tr class="lineB">
<td>
<font class="label">6.</font>
</td>
<td>
<font class="label">Do you have any adverse information about this person's employment, residence or activities concerning the following? Respond YES or NO to the following questions. If yes, please explain. </font>
</td>
</tr>
</tbody>
</table>
<table>
<tbody>
<tr>
<td colspan="2" valign="top">
<font class="label"> </font>
</td>
<td align="center" width="8%">
<font class="label">YES</font>
</td>
<td align="center" width="8%">
<font class="label">NO</font>
</td>
</tr>
<tr class="lineA">
<td class="list">
<font class="label"> </font>
</td>
<td>
<font class="label">(a) Drug / Alcohol Abuse </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ10" value="Yes"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ10" value="No"></font>
</td>
</tr>
<tr class="lineB">
<td>
<font class="label"> </font>
</td>
<td>
<font class="label">(b) Sexual Abuse of Children </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ11" value="Yes"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ11" value="No"></font>
</td>
</tr>
<tr class="lineA">
<td class="list">
<font class="label"> </font>
</td>
<td>
<font class="label">(c) Child Abuse </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ12" value="Yes"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ12" value="No"></font>
</td>
</tr>
<tr class="lineB">
<td>
<font class="label"> </font>
</td>
<td>
<font class="label">(d) Crime or violations of the law </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ13" value="Yes"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ13" value="No"></font>
</td>
</tr>
<tr class="lineA">
<td class="list">
<font class="label"> </font>
</td>
<td>
<font class="label">(e) Other matters </font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ17" value="Yes"></font>
</td>
<td align="center">
<font class="entry"><input type="radio" name="EvalRadioQ17" value="No"></font>
</td>
</tr>
</tbody>
</table>
<table>
<tbody>
<tr>
<td> </td>
<td colspan="3">
<font class="label">If you answered YES, please provide explanation below:</font>
</td>
</tr>
<tr>
<td> </td>
<td colspan="3">
<font class="entry"><textarea name="EvalLongTextQ6" rows="4" cols="72"></textarea></font>
</td>
</tr>
</tbody>
</table>
<br>
<table cellspacing="1" cellpadding="1" width="100%" border="0">
<tbody>
<tr>
<td>
<font class="label">7.</font>
</td>
<td>
<font class="label">Do you know of any reason why the applicant should not be employed to work with children?</font> <font class="entry"><input type="radio" name="EvalRadioQ14" value="Yes"></font> <font class="label">
Yes</font> <font class="entry"><input type="radio" name="EvalRadioQ14" value="No"></font> <font class="label">No</font>
</td>
</tr>
<tr>
<td> </td>
<td>
<font class="label">Comments:</font>
</td>
</tr>
<tr>
<td> </td>
<td>
<font class="entry"><textarea name="EvalLongTextQ1" rows="4" cols="72"></textarea></font>
</td>
</tr>
<tr>
<td>
<font class="label">8.</font>
</td>
<td>
<font class="label">Has the applicant been dismissed, non-renewed, or asked to resign from your school division / company?</font> <font class="entry"><input type="radio" name="EvalRadioQ15" value="Yes"></font> <font
class="label">Yes</font> <font class="entry"><input type="radio" name="EvalRadioQ15" value="No"></font> <font class="label">No</font>
</td>
</tr>
<tr>
<td> </td>
<td>
<font class="label">Comments:</font>
</td>
</tr>
<tr>
<td> </td>
<td>
<font class="entry"><textarea name="EvalLongTextQ2" rows="4" cols="72"></textarea></font>
</td>
</tr>
<tr>
<td>
<font class="label">9.</font>
</td>
<td>
<font class="label">Is the applicant <b>eligible</b> for reemployment if he / she was to reapply?</font> <font class="entry"><input type="radio" name="EvalRadioQ16" value="Yes"></font> <font class="label">Yes</font>
<font class="entry"><input type="radio" name="EvalRadioQ16" value="No"></font> <font class="label">No</font>
</td>
</tr>
<tr>
<td> </td>
<td>
<font class="label">Comments:</font>
</td>
</tr>
<tr>
<td> </td>
<td>
<font class="entry"><textarea name="EvalLongTextQ3" rows="4" cols="72"></textarea></font>
</td>
</tr>
<tr>
<td>
<font class="label">10.</font>
</td>
<td>
<font class="label">Do you have any additional comments about the applicant?</font>
</td>
</tr>
<tr>
<td> </td>
<td>
<font class="entry"><textarea name="EvalLongTextQ4" rows="4" cols="72"></textarea></font>
</td>
</tr>
</tbody>
</table>
<br>
<table>
<tbody>
<tr>
<td>
<font class="label">NOTES</font>
</td>
</tr>
<tr>
<td>
<font class="entry"><textarea name="EvalLongTextQ5" rows="4" cols="72"></textarea></font>
</td>
</tr>
</tbody>
</table>
<br>
<table>
<tbody>
<tr>
<td>
<font class="label">Name: </font>
</td>
<td>
<font class="entry"><input type="text" name="RefCheckBy" size="40" maxlength="50"></font> <img border="0" src="images/reqd.gif" alt="Required Field">
</td>
<td>
<font class="label">Date: </font>
</td>
<td>
<font class="entry"><input type="text" name="RefDate" size="10" maxlength="10"></font> <img src="images/calendar.gif" style="border:0; vertical-align:middle;"
onclick="showCalendar(this,document.forms[0].RefDate, 'MM/DD/YYYY',null,1,-1,-1)"> <img border="0" src="images/reqd.gif" alt="Required Field"> (MM/DD/YYYY)
</td>
</tr>
</tbody>
</table>
<br>
<font class="label"><img border="0" src="images/reqd.gif" alt="Required Field"> indicates required field</font>
<br>
<center>
<table>
<tbody>
<tr>
<td><input type="submit" value="Save"></td>
<td><input type="button" value="Cancel" name="pbCancel" onclick="pbcancelclick(this)"></td>
</tr>
</tbody>
</table>
</center>
<input type="hidden" name="PageInstance" value="01DADFA66AAC1A80">
<input type="hidden" name="FormContext" value="DEFAULT">
<input type="hidden" name="IsFormDataValid" value="">
<input type="hidden" name="Action">
<input type="hidden" name="Session">
</form>Text Content
Prince William County Public Schools Pre-Employment Reference Check Ref #: 00818155 Instructions: Your name has been provided to assist in completing a background investigation to help us determine this person’s suitability for employment. Therefore, we ask that you complete all items on this form as soon as possible so we can complete the process in a timely and efficient manner. PWCS keeps information confidential and does not share it with the candidate or other party unless release or disclosure is otherwise required by law or deemed necessary by PWCS. APPLICANT Applicant Name: Derya KOC PID: 310638 Positions Applied For: ADMINISTRATIVE ASSISTANT II - 223 DAYCENTRAL OFFICE FINANCE SPECIALIST II - 250 DAY - OPEN UNTIL FILLEDDATA CONTROL SPECIALIST II - 250 DAYOFFICE ASSISTANT - 195 DAYTEACHER ASSISTANT - 188 DAY Employment Confirmation Start Date: (MM/DD/YYYY) End Date: (MM/DD/YYYY) REFERENCE CONTACT Contact Name: Home Phone: School Div. or Company: Position: Work Phone: Please indicate your relationship to this candidate <No Selection>Coworker/PeerDepartment Chair/Team LeadMentorOtherPersonal (Friend/Family)ProfessorSupervisor - EmploymentSupervisor – Volunteer Work Please provide what the relationship was: EVALUATION EXCELLENT GOOD FAIR POOR N/A Relationships with: 1. (a) Staff (b) Students (c) Parents (d) Supervisor(s) 2. General Behavior or Conduct 3. Dependability & Attendance 4. Attitude at Work 5. Overall Job Performance 6. Do you have any adverse information about this person's employment, residence or activities concerning the following? Respond YES or NO to the following questions. If yes, please explain. YES NO (a) Drug / Alcohol Abuse (b) Sexual Abuse of Children (c) Child Abuse (d) Crime or violations of the law (e) Other matters If you answered YES, please provide explanation below: 7. Do you know of any reason why the applicant should not be employed to work with children? Yes No Comments: 8. Has the applicant been dismissed, non-renewed, or asked to resign from your school division / company? Yes No Comments: 9. Is the applicant eligible for reemployment if he / she was to reapply? Yes No Comments: 10. Do you have any additional comments about the applicant? NOTES Name: Date: (MM/DD/YYYY) indicates required field