[INSERT LOGO HERE]
COMPANY NAME
REFERENCE REQUEST FORM
Name [of employee or prospective employee]:
The person named above (the applicant) has applied for employment with this organisation in the post of
[job title]. This post will involve the following key job duties [list key job duties] [and is at a
junior/supervisory/management/senior management level].
We are seeking a reference in respect of the applicant, who has given his/her consent for us to approach
you for this purpose.
We would be grateful if you could answer the following questions as fully as possible:
Did the applicant work for your organisation? Yes No
If yes, what were the applicant's start and leaving dates?
Start date:
Leaving date:
What was the applicant's job title with your organisation?
What were the applicant's main job duties?
Did the applicant have supervisory responsibility for other staff? Yes No
Did the applicant have any responsibility for recruitment, appraisal, discipline or
Yes No
dismissal?
Did the applicant have any responsibility for money, materials or goods? Yes No
Did the applicant have any responsibility for computer operations or computer
Yes No
programming?
What is your assessment of the following elements in relation to the applicant?
Excellent Good Fair Poor
Quality of work
Quantity of work
Dedication to the job
Ability to work
without supervision
Working relationships
Did you find the applicant to be honest and trustworthy? Yes No
Did you find the applicant to be reliable in carrying out his/her duties? Yes No
Was the applicant's time-keeping satisfactory? Yes No
[INSERT LOGO HERE]
Did the applicant have any disciplinary warnings during his/her last 12 months'
employment with your organisation? If so, please comment, if possible on the nature of Yes No
these warnings:
What was the reason for the applicant leaving your organisation?
Do you think the applicant would be a suitable person to perform the job described
Yes No
above?
Would you re-employ the applicant? Yes No
Please comment further, if possible, on the applicant's suitability for employment into the post described above.
Any information that you choose to give us will be treated in the strictest confidence. Thank you very much for
your assistance.
This document is for general information purposes only. While we endeavour to keep the information up to date and
correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy,
reliability, or suitability with respect to the content of this document.
In no event will we be liable for any loss or damage including without limitation, indirect or consequential loss or damage,
or any loss or damage whatsoever arising from the use of the documents.
