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?

    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?


    Is there any other information we should know about the applicant?

    Please select:




    Honesty / integrity


    Relationships with people they support

    Relationships with staff / colleagues



    Name (please print):




    Job title / Position:






    Contact phone number:


    Please put company stamp here (jpg, pdf or doc):