Form FL5-127 Inquiry Concerning Application for Employment

DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To:

.

has applied for appointment as a
in the Department of Veterans Affairs and has given your name as a personal reference or as a present or former supervisor or
employer.
To help us determine whether this applicant meets requirements for employment, we ask that you complete the statements on the
reverse of this letter. Please be entirely frank, and answer all applicable questions as fully as specifically as you can.
If possible, please return this form within 7 days. An addressed envelope requiring no postage is enclosed for your convenience.
Thank you for your help.
Sincerely yours,

Enclosures

PRIVACY ACT NOTICE: Title 5, United States Code, grants VA the authority to make inquiries concerning the
fitness and qualifications of applicants for employment in VA. While you are not required to respond, your
cooperation in providing this relevant and necessary information is voluntary. The information you provide on the
above-named individual will be disclosed to the individual on his or her request. You have the right to request that
your identity not be disclosed to the individual (38 U.S.C. 3301). If you ask that your identity not be disclosed to the
individual, the confidentiality applies only to your identity and to information that, if released, would identify you as
the source. The information may be disclosed outside the VA only if disclosure is authorized by the Privacy Act.
Please check one of the blocks below to indicate your preference.
Yes, you may disclose my identity to the above-named individual.
No, please do not disclose my identity to the above-named individual.

FRONT -- Page 1 of 2

FL 5-127
AUG 2009 (RS)

Adobe LiveCycle Designer

OMB Approved No.: 2900-0117
Respondent Burden: 15 Minutes

INQUIRY CONCERNING APPLICANT FOR EMPLOYMENT
RESPONDENT BURDEN: Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the VA Clearance Officer (005R1B),
810 Vermont Avenue, NW, Washington, D.C. 20420. VA may not conduct, sponsor or require you to respond to this collection of information unless it displays a valid
OMB Control Number. DO NOT send request for benefits to these addresses.
1. HOW WAS YOUR KNOWLEDGE OF THE APPLICANT OBTAINED?
APPLICANT'S EMPLOYER

AS APPLICANT'S SUPERVISOR

CO-WORKER

PERSONAL FRIEND

OTHER (Specify)

2. HOW LONG HAVE YOU KNOWN THE APPLICANT?

NOTE: Complete Items 3 through 9 ONLY if you have been applicant's employer or supervisor.
3. BRIEF DESCRIPTION OF APPLICANT'S DUTIES IN LAST POSITION WITH YOU

4. INCLUSIVE DATES OF ABOVE POSITION

5. SALARY

6. NUMBER AND TYPE OF EMPLOYEES SUPERVISED BY APPLICANT

$
7. EVALUATION OF APPLICANT'S PERFORMANCE
NOTE: Please check the approprite column
for each item.

BELOW
AVERAGE

WEAK

ABOVE
AVERAGE

SATISFACTORY

SUPERIOR

NOT
OBSERVED

A. QUANTITY OF WORK
B. QUALITY OF WORK
C. KNOWLEDGE
D. ORIGINALITY
E. DEPENDABILITY AND ATTENDANCE
F. RELATIONSHIPS WITH OTHERS
G. ACCEPTANCE OF SUPERVISION
8. IF CIRCUMSTANCES PERMITTED, WOULD YOU REHIRE THE APPLICANT?
NO (If "YES," give reason.)

YES

9. REASON APPLICANT LEFT YOUR EMPLOYMENT

NOTE: All addressees are requested to complete the remaining Items.
10A. TO YOUR KNOWLEDGE, HAS THE APPLICANT LOST A JOB
WITHIN THE LAST 5 YEARS BECAUSE HIS/HER CONDUCT
OR WORK WAS NOT SATISFACTORY?
YES

10B. NAME AND ADDRESS OF EMPLOYER

NO (If "YES," complete 10B, 10C, and 10D.)
10D. TO YOUR KNOWLEDGE, WAS THE APPLICANT
NOTIFIED AS TO THE REASON FOR DISCHARGE?

10C. REASON FOR DISCHARGE OR RESIGNATION

YES

NO

11. TO YOUR KNOWLEDGE, IS THE PERSON RELIABLE, HONEST, TRUSTWORTHY, AND OF GOOD CHARACTER?
YES

NO (If "NO," explain fully in Item 13.)

12. WOULD YOU RECOMMEND THE APPLICANT FOR THE JOB WHICH HE/SHE HAS APPLIED?
YES

NO (If "NO," explain fully in Item 13.)

13. USE THIS SPACE AND ADDITIONAL SHEETS, IF NECESSARY TO SUPPLY ANY OTHER PERTINENT INFORMATION AND FURTHER EXPLANATION YOU MAY WISH
TO MAKE IN CONNECTION WITH YOUR ABOVE ANSWERS.

14. SIGNATURE

FL5-127
AUG 2009 (RS)

15. TITLE OR OCCUPATION

16. DATE

Adobe LiveCycle Designer