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To order - fill out the following form and submit it by fax or email attachment as per directions below
By your signature on the form requesting our employment reference investigation services, you agree that you have read, understand, and accept the following policies and stipulations.
· Legal Services:  ReferenceClinic.com and its parent LDA Enterprises, Ltd. is not a law firm, nor do we employ attorneys.  However, we will be available on a for-fee basis to provide certain services to you or to the attorney of your choice.  These services may include written or in-person depositions or providing expert witness testimony.  Fees for these services are listed under our optional services and support fees section.
Time required for completion:
We cannot guarantee a specific time frame for the completion of your reference investigation.  Most reference checks can be completed and a report sent within 7 business days.  However a variety of situations can impact our ability to verify your references.  All references are obtained by direct phone conversation unless the contact you have provided, or a particular company policy, requires that we request the reference or verification in writing.  Your contact may not respond to our requests, may be traveling, on vacation, etc.  Therefore, we will make up to four attempts to reach each of your contacts by telephone.  If we are unable to reach any of your contacts by phone within 7 business days, we will make an effort to contact the Human Resource or Personnel Department to verify job title, dates of employment, and any other information they might be willing to provide.  Under any circumstances, we will email a copy of the report to you as soon as it is available.  If requested a hardcopy of your final report will also be sent to your designated address by first class U.S. mail within 2-weeks of our receipt of your prepaid order.  The final emailed report will consist of all information we have received, or advise you that your contact has not been available or responsive to our attempts at communication.
Statement of Confidentiality:
All information provided by or about you will remain totally confidential and we will never reveal that you are the source requesting information.  We fully understand the sensitivity associated with obtaining personal information.  In these days of identity theft and the proliferation of companies selling private information, it is important to understand that your information is totally secure with us.  We inform all companies and individuals from whom we seek a reference only that we are a “human resource management firm” checking references on behalf of one of our clients.  L.D.A. Enterprises, Ltd. does not sell lists of clients or in any other way disseminate personal information provided by our clients to any third party or organization for any reason without your prior written consent.
Refund Policy:
The ReferenceClinic cannot guarantee that any specific contact will return our calls or that an employer will provide information about former employees.  It is a human resource management policy of many employers that they only disclose dates of employment and verify job titles.  Some personnel departments will also corroborate income.  You as the client have an obligation to furnish us with accurate contact information so that we can reach your references.  If your information is outdated or inaccurate, it will impede our efforts to reach those people and provide a timely response to you.  If a specific contact does not return our calls after four (4) attempts, we will try to verify information through the personnel or human resource department.  It is important to note that not all companies have a formal human resource function, and not all employers will respond to our repeated attempts at contact.  Therefore we cannot be responsible for either professional or personal reference contacts that do not return our calls or repeated requests for information.  Neither are we responsible for providing information beyond what a specific reference or human resource department is willing to divulge.  Since a potential employer will typically face the same obstacles in obtaining references that Reference Clinic experiences, the information we are able to gain is normally what any potential employer who is checking references will experience.  Because we do guarantee to extend our maximum effort to satisfy you as a client, and since we are also providing you with services and information that goes beyond the actual reference investigation, our fees or any portion of them are non-refundable.



Please submit one form for each individual reference you need verified (you only need to put your personal information and charge card information on the first form).



All information you provide is considered completely confidential and will not be released to any third party or organization without your written consent.  We will never inform anyone that you are the person requesting this reference investigation. 


TO ORDER: You may copy and paste the following order form into an email, cut it out and fax it to the number listed below, or send it by regular U.S. mail to the address indicated.



ReferenceClinic.com                                                                        Phone: (952) 697-3663

LDA Enterprises, Ltd.                                                                    Fax: (952) 697-3667

West End Plaza, 1660 South Hwy 100, Suite 500

St. Louis Park, MN 55416

Email: References@EmploymentClinic.com



Your Personal Information:


Name (Mr. or Ms.): _______________________________________________________


Social Security Number (This is optional information, but many employers will not release personal information without a Social Security number as identification): ______________________________


Address: ___________________________________________________________________


City: ____________________________________ State: ________ Zip Code: ___________


Home Phone: __________________________ Business Phone: __________________________


Fax number: ______________________________ Email: ______________________________



Employer Contact Information: (The person to contact for a reference)


Please provide us with the following contact information for each reference you wish verified.  Fill out only those spaces that are applicable.  Copy and add additional requests as necessary.


Name of Contact: _____________________________________ Title: __________________________

Relationship with contact if this is a previous employer (i.e. immediate supervisor, Plant Manager, company Vice President, company President, colleague, board member, etc.):



Company name: ____________________________________________________________________


Company address: __________________________________________________________________


City: ______________________________ State: _____________ Zip Code: __________________


Contact Phone number _____________________________ Email: _______________________


Corporate Phone number (if contact cannot be reached): ___________________________




Your position title: ______________________ Dates of employment: ______________________


Position description: _____________________________________________________________


Salary to be confirmed (your ending salary compensation): _______________________________


Reason for your separation: ________________________________________________________


List any special concerns or additional information that may be important as we attempt to verify your reference: _________________________________________________________________________








 Non-employer contact information (if this is a character reference)


Name of Contact: ___________________________________ Position: ___________________


Your relationship to this contact: __________________________________________________


Home Phone: ______________________ Business Phone: ____________________________


Agreement Statement:


By your signature below you acknowledge that you have read and agree to the policies and stipulations as published on the Reference Checking Policies and Stipulations webpage and authorize The ReferenceClinic and its employees or agents to contact the above named employer, its representatives and employees, or other named professional or personal contact to furnish information about you including: dates of employment, wage history, performance, attendance, reason for separation, areas for improvement, and any other statements or comments obtained through our reference checking process.  Furthermore, you stipulate that the information herein contained is your own personal information and is, to the best of your knowledge, truthful and accurate. You understand that The ReferenceClinic cannot give any guarantees regarding exact results or the time frame in which those results can be provided, and that fees paid are not subject to refund once a reference investigation has been initiated.  You also agree to indemnify, release, and hold harmless The ReferenceClinic and its agents or employees from any damages, liability, loss of income or profits, or any other claim based upon information we may provide as a result of our investigation or your utilization of that information.   You understand that all information provided by or about you will remain totally confidential, will not be released to any third party, and we will never reveal that you are the source requesting information. 


Client Signature: ________________________________________ Date: ________________      


                                       Order Information – please select your service:


    One standard reference investigation - $104.95

     Two or more standard reference investigations - $99.95 each


         Quantity ordered ___________   Total Amount $___________ 


          One executive reference investigation - $119.95


    Two or more executive reference investigations - $114.95 each


         Quantity ordered ___________   Total Amount $__________


  • Reports will be emailed to your provided email address

Optional services and support fees (applies to all reference checking investigations).  Fees for other services appear on our ReferenceClinic.com home page and include expert witness testimony and deposition charges.


The following charges are in addition to all fees quoted above.  Please check applicable boxes.


  • Reports sent by email and 1st class U.S. mail - Included
  • Faxed reports - $15.00
  • Reports by telephone - not available
  • Notarized affidavits - $15.00 per report
  • Canadian reference investigation report - $15.00 per report
  • Telephone depositions - $250 per hour (1-hour minimum)
  • Expert witness testimony or in-person depositions – $1,850 per day, per person attending (one-day minimum) Plus all applicable expenses
  • Email consultations – all career issues   $35.00 per detailed emailed response or $90.00 for 3 questions
  • Telephone discussions – all career issues   $80.00 per ½ hour session or $150.00 per one-hour session



Total cost of optional services (if any)                              $____________


Total charges including optional services                        $____________



Please check one: Visa ____ MasterCard ____ American Express ____ Check ____  


Card number: ___________________________Expiration date: ________________


** Charge card security code ________ (last 3 numbers on the back of your Visa or MasterCard typically on the right hand side of the signature strip) or (the 4 number code on the front of the American Express Card, on the right hand side just above your card number.)


Card holder's Name (exactly as it appears on the card): _________________________________


Billing address of the cardholder: ____________________________________________


City: _________________________ State: __________ Zip Code:  ________________


Signature: ____________________________________ Date: _______________________


You may pay check, Visa/MasterCard, or American Express.  If you are paying by check, your check and authorization form (this form) should be signed and mailed to the address below.  If paying by credit card, you may also email these forms or fax the completed and signed forms to our secure fax line: (952) 697-3667, attention Edna Campbell. 


LDA Enterprises, Ltd.

West End Plaza, 1660 South Highway 100, Suite 500

St. Louis Park, MN 55416

Attention: Edna Campbell


Email address: References@EmploymentClinic.com


LDA Enterprises Ltd.
West End Plaza, 1660 South Highway 100, Suite 500, St. Louis Park, MN 55416
Phone: (952) 697-3663 Fax: (952) 697-3667
Copyright © 2018 LDA Enterprises, Ltd. All rights reserved.