Applicant’s Name:
Post Applied for:
Please fill in the relevant selection, either 1A, 1B, 1C or 1D below
1A REFERENCE FROM CURRENT / PREVIOUS EMPLOYER
In what capacity do/did you know the applicant? ……………………………………………………
During which dates did you employ the applicant: From: To:
Does the applicant have any disciplinary warnings on file, and if so please provide brief details:
…………………………………………………………………………………………………………
How would rate the applicant’s performance in respect of absence and timekeeping?
…………………………………………………………………………………………………………
Please give details of sick leave taken in the last 12 months:
…………………………………………………………………………………………………………
1B PERSONAL REFERENCE
For how long have you known the applicant? From: To:
In what capacity? ……………………………………………………………………………………..
1C SCHOOL/COLLEGE/UNIVERSITY
If the applicant was a student at your school, college or university, please give the dates during
which the applicant was studying: From: To:
Course Title: ……………………………………………………………………………………………
1D PROFESSIONAL REFERENCE: GP/SOLICITOR/POLICE/MAGISTRATE/MP
For how long have you known the applicant? From: To:
In what capacity? ……………………………………………………………………………………….
Please complete Question 2 only if you are providing an employer’s reference
2. How was/will the employment terminated? Please delete as appropriate:
Resignation Dismissal Compulsory redundancy Voluntary redundancy
Would you re-employ? Yes / No
Please complete Question 3 only if you are providing a Professional or School/College/University
reference
3. ABSENCE RECORD
Number of incidences of absence/sickness in the last 12 months: ……….
Total number of days: ……
Please comment on the attendance, health record and any specific mental or physical health
problems or unusual behaviour.
……………………………………………………………………………………………………………….
……………………………………………………………………………………………………………….
All referees please complete Question 4, 5, 6 and 7
4. ATTRIBUTE / SKILLS Please rate the applicant in terms of each of the following:
Excellent Good Fair Poor N/A Comments
Quality of Work
Punctuality/Reliability
Ability to work under
pressure
Ability to work as part of
a team
Communication – oral
Communication – written
Initiative
Honesty / Integrity
Trustworthiness
Attitude with colleagues
Ability to work without
supervision
Comments may be continued on a separate sheet.
5. Criminal Convictions
In view of the possible vulnerable nature of the clients, this work is excluded from the operation of the
Rehabilitation of Offenders Act 1974, which means you may mention any convictions the applicant
has of which you are aware. To the best of your knowledge has the applicant been charged or
convicted with any offence involving violence, fraud, or dishonesty or been subject of any criminal
proceedings? Yes / No
……………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………..
6. ANY OTHER INFORMATION OR COMMENTS WHICH YOU FEEL MAY BE USEFUL:
……………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………..
7. DETAILS ABOUT PERSON COMPLETING THIS REFERNCE REQUEST
Signature: _________________ Print name: ___________________________
Date: _______________ Position: _______________________________
Relationship to candidate: ________________ Tel no: ______________________________