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Reference Request Form

This reference request form collects information about a job applicant from a previous employer. It requests details such as the applicant's job title and dates of employment, reasons for leaving, any disciplinary actions or warnings, sickness absence, parental leave taken, key duties and responsibilities, and performance ratings. The referee is asked to comment on the applicant's suitability for the position and whether they experienced any problems with relationships. By signing, the referee agrees the information is accurate and consents to its disclosure to the applicant.

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Cosmina Catina Mihaila
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© © All Rights Reserved
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87 views4 pages

Reference Request Form

This reference request form collects information about a job applicant from a previous employer. It requests details such as the applicant's job title and dates of employment, reasons for leaving, any disciplinary actions or warnings, sickness absence, parental leave taken, key duties and responsibilities, and performance ratings. The referee is asked to comment on the applicant's suitability for the position and whether they experienced any problems with relationships. By signing, the referee agrees the information is accurate and consents to its disclosure to the applicant.

Uploaded by

Cosmina Catina Mihaila
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Reference Request Form

Position Applied for


Name of Applicant
Job Applied for
(please refer attached job description)
Work Location

Please Outline
Capacity in which you know the Applicant
How long have you known the Applicant?
Job held by Applicant
Dates of Employment
Reason for leaving

Any current warnings/disciplinary action for performance, attendance or


conduct? If Yes, please provide detail

Yes / No

Have you referred the Applicant to DBS/NMC or any other regularity or


professional body? If Yes, please provide detail

Yes / No

Would you re-employ the candidate? If no, why not?

Yes / No

Absence whilst in your employment


Sickness
Absence

Applicant has had ____ episodes of sickness absence in the past three years totalling ____ days

Reference Request Form


Rev 01 May2013

Page 1 of 2

Parental
Leave

Applicant has taken ____ days parental leave

Please provide an overview of the applicants key duties & responsibilities whilst in your employment.

Please assess against these performance criteria (please tick() as appropriate)


Excellent

Good

Satisfactory

Variable

Poor

(please expand below)

Competence in the job


Ability to work without supervision
Attitude/ Co-operation
Communication skills (oral & written)
Professional Conduct
Reliability
Timekeeping
Honesty/Integrity

Please comment on the candidates suitability for the post (refer attached job description) taking into
account ability, professional and personal characteristics as well as managerial ability, if appropriate,
and any other factors which you consider relevant.

Reference Request Form


Rev 01 May2013

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Teamwork is paramount to the successful running of our facilities. In your opinion, has the candidate
ever experienced any problems regarding relationships with others?

Please use the space below, to provide any additional information you think may be relevant.

In signing this document you agree that the information provided is a) accurate and b) unless you
indicate to the contrary, you consent under the Data Protection Legislation to this information being
disclosed to a third party such as the employee to whom this reference applies.
Please tick () as appropriate.

I agree

I disagree

Name
Company
Position

Reference Request Form


Rev 01 May2013

Page 3 of 2

Date
Signature

Reference Request Form


Rev 01 May2013

Page 4 of 2

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