Online Reference Request Form

Name*

First Last

Referee Name*

Referee Email Address*

Referee's Company / Organisation*

Company / Organisation Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Company Telephone Number Phone*

What is/was your relationship to the applicant?*

How long have you known the applicant?*

In what capacity do you know the candidate? (Friend or Employer)*

Date Employment Commenced*

Date Employment Ceased*

Position held with the company*

Role and Responsibilities*

Reason for leaving and final salary*

Was the candidates timekeeping of a good standard?*

Yes
No
Sometimes

Was the candidates attendance of a good standard?*

Yes
No

How many days sickness did the candidate have in the last 2 years, whilst in your employment?*

How well does the candidate meet the criteria?*

Would you consider the applicant able to maintain confidentiality?*

Yes
No (please provide more details in the box below)

If no - please provide reasons why

Has the applicant ever been subject to a formal disciplinary procedure during their time with you?*

Yes
No

If yes - please provide reasons why

HM Government guidelines "Working Together to Safeguard Children" illustrate the need for individuals and organisations to work together in safeguarding children. Safeguarding children is everyone’s responsibility. Is there anything you should tell us about the applicant’s suitability to work with children?*

Yes (please provide more details in the box below)
No

If you have answered yes to the question above, please provide more details here

To your knowledge or experience, is there any reason why this applicant should not work in an Early Years setting?*

Yes
No

If you have answered yes to the question above, please provide more details here

Would you re-employ the applicant?*

Yes
No (please provide more details in the box below)

If you have answered no to the question above, please provide more details here

Do you give permission for these details to be disclosed to the applicant?*

Yes
No

Confirmation*

I confirm that to my knowledge all the information supplied is correct:
I can not confirm that to my knowledge all the information supplied is correct:

Date*