Employer Reference Request
Please attach a company compliment slip to this reference, or use a company stamp to endorse your reply.
Applicant’s name:
Applicant’s job title:
Date of employment:
Start date
End date
Reason for leaving:
Are you aware of any back or neck injuries or other medical conditions that may affect the applicant’s ability to do the work described?
YesNo
Are there any disciplinaries in place or pending during last 12 months of employment?
HMS is exempt from the Rehabilitation of Offenders Act.
Are you aware of any convictions (spent or otherwise) that the applicant may have?
Are you related in any way to the applicant?
If ‘Yes’ please explain:
Would you re-employ the applicant?
If ‘No’ please explain the reasons why:
How much sickness did the applicant have in the last 12 months of employment?
Days
Is there any other information we should know about the applicant?
Please select:
Attendance
ExcellentGoodSatisfactoryFairPoor
Experience
Flexibility
Honesty / integrity
Punctuality
Relationships with people they support
Relationships with staff / colleagues
Reliability
Name (please print):
Email:
Job title / Position:
Date:
Company:
Contact phone number:
Please put company stamp here (jpg, pdf or doc):
