CONFIDENTIAL REFERENCE FORM
1. Personal Details:
Name of Candidate:
Post Applied for:
Reference Number:
2. Employment Details:
Occupation in your employment:
Date of Employment From: To:
Reason for Leaving:
Do you know of any reason why we should not Yes / No
employ this person?
If yes, please state the reason
Would you re-employ this person? Yes / No
If No, please state the reason:
Has the applicant got any live disciplinary Yes / No
outcomes on their file?
If Yes, please indicate the nature:
Please state how long you have known this
person and in what capacity e.g. Line
Manager?
3. Rehabilitation of Offenders Act:
In order to protect the public this post is exempt from the provisions of Section 4(2) of the Rehabilitation of Offenders Act
1974. It is therefore not contrary to the Act to reveal any information you may have concerning convictions which would
otherwise be considered as “spent” in relation to this application and which you consider relevant to the applicant’s suitability
for employment. Any such information will be kept in strict confidence and used only in consideration of the suitability of this
candidate for a position where such an exemption is appropriate.
To the best of your knowledge are you aware of Yes / No
any criminal convictions?
If Yes please give details:
4. Attendance Record:
Please confirm sickness record in the last 2 Total number of days sick:
years:
Total number of occasions sick:
Have you any concerns about the candidates Yes / No.
health record:
If Yes, please comment:
Was the candidate’s timekeeping of a Yes / No
satisfactory standard:
If No, please comment:
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5. Candidate Suitability
Please give details of the applicant’s suitability or otherwise for the post, a job description and person
specification are enclosed for information. The following headings are suggested for guidance:
communication; initiative; creativity; motivation; commitment; integrity; reliability; competence.
(Please continue on a separate sheet if necessary)
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Signed: ___________________________________________ Date: _____________________
Name: ___________________________________________ Position: __________________
(Block Capitals)
Your Company Stamp: (if applicable)
Please return the form to:
Mr. I. SOMAUROO Company Director
The Meadows Residential Care Home
288, Oldfield Lane North
Greenford
Middlesex UB6 8PS.
