Name of applicant:
1.       In what capacity do you know the applicant? (e.g. as a former employee, friend, etc)
2.       How many years have you known the Applicant?
3.       In your opinion is the applicant an honest and reliable person?
4.       Please write here any other comments you would like to make regarding the applicant, and which would be of interest to a prospective employer.

(Please continue on a separate sheet if necessary)


(Questions 5-8 to be answered by former employers only)
5.       (a) Please state the dates during which the applicant was employed by you or your organisation and in what capacity they were employed.
(b) During the period the applicant was employed by you, would you say their timekeeping was:

(i)   good

(ii)  average, or

(iii)  below average?

(c)  (i) how many days sickness has the       applicant taken in the last year?

(ii) how many periods of sickness has this consisted of?

(d)  Did the applicant take parental leave and if so:

(i)  for how long; and

(ii)  what was the name of the child?

6.       Would you re-employ the applicant?  If not, why not?
7.       What was the applicant’s reason for leaving your employment?
8.       What was the applicant’s salary at the time of leaving?


Is this reference given in confidence? YES/NO (delete as appropriate)

(if applicable company stamp)

Name of person signing: