Applicant full Name

Your First Name

Your Last Name

Your Job Title

Your Work Email

Your Work Telephone number

Company Name & Address where you worked with applicant

Applicant Job title

Relationship with applicant

Is the Applicant Still employed
YesNo
Date employed from

Date employed to

Reason for Leaving (if applicable)

How many days was the applicant
absent (including period of sickness)
during the last 12 months of
employment:

Would you Re-employ applicant, if
answer is No please provide further
information below?
YesNo
Comments/Further information

Please comment on the following below :
General Conduct
ExcellentGoodSatisfactoryPoor
Timekeeping
ExcellentGoodSatisfactoryPoor
Communication skills
ExcellentGoodSatisfactoryPoor
Relationship with colleagues
ExcellentGoodSatisfactoryPoor
Relationship with
customers/patients/service users
ExcellentGoodSatisfactoryPoor
Are you aware of any proceedings, Policy investigations or disciplinary action?

Declaration
I declare that to the best of my knowledge the information I have given in this reference is correct and complete

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