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Name of Applicant Position Applied For Company Company / Hospital In what Capacity was he/she employed Is this Candidate

!nown to yo" personally (if so, how long and what capacity?) Please $i%e &rief description of nat"re of d"ties Dates Employed - From: #es / No To:

To the &est of yo"r !nowled$e' please tic! the appropriate &o( ) ) ) E(cellent *ood Fair Time Keeping Attendance Ability Conduct Please state sic!ness record o%er the last +, months No of Days No of Episodes

Poor

Please state reason for lea%in$ -o"ld yo" re-employ the Candidate (if no, please state why)

#es / No

Any f"rther Comments ) ) )

SIGNED: NAME: (in block capitals) OFFICIAL COMPANY STAMP:

DATED: POSITION: COMPANY ADDRESS:

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