reference request

EMPLOYMENT HISTORY:
Name:

Period of employment:
From: To:

Reason for leaving:

Job title:

Salary/Wage:

Number of weeks parental leave

taken during employment:

Would you re-employ:

Yes  No
If no please state reason:

Please tick the following:

Excellen Very Good Average Poor
t Good
Appearance

Attendance

Punctuality/Time keeping

Co-operation/Attitude

Honesty/Integrity

Performance of duties

Reliability

Willingness to learn

Working relationships with

colleagues

Please provide any further information that may be relevant

Signature: Name:

Position: Date:

Company name:

The above information will be treated in the strictest confidence.

Thank you for your time in providing this information.