Title: Request for Reference

Issue 1
Issue Date 03/10/2022
Page 1 of 2

Request for Reference

Name of referee:

Position in relation to applicant:

Name of applicant:

Position applied for:

Dates of employment: From:
To:
Please list their main duties:

Reason for leaving:

Was the Applicant under investigation at the time of their leaving due to
allegations regarding their conduct at work? If Yes, please give details: Yes/No

Does the Applicant have any unexpired formal disciplinary warnings on

their record? If Yes, please give details for level of warning, date issued
Yes/No
and duration

Absence: please state the number of days absent, and the number of occasions in the past 12
months:

Are you aware of any other circumstance that would make it undesirable Yes/No
to engage the Applicant in employment?

Would you re-employ the Applicant? If No, please detail below: Yes/No

Please give an opinion as to the following:

Very good Good Average Poor

Honesty

Loyalty

Reliability
 Ability to work unsupervised

Ability to use own initiative

Timekeeping

Personal appearance

Signature of referee: ​ ​ ​ ​ ​ ​Date:

All information will be treated in the strictest of confidence