Employer’s reference

To be completed by a Human Resources representative or the applicant’s line manager.

THIS FORM MUST NOT BE COMPLETED BY THE APPLICANT.

Applicant’s name

GMC reference number

Period of employment From D D M M Y Y Y Y To D D M M Y Y Y Y

Position held by applicant

Brief description of duties

Are you aware of any issues that call into question this doctor’s character, conduct or fitness to
practise? YES □ NO □
(For example have they been subject to any disciplinary proceedings whilst employed by you) Please tick a box

If “yes,” please provide details

I confirm that the information I have given is true and accurate to the best of my knowledge

Full name Position

Telephone number Email

This should be an official
This should be an official work
work email address not a
telephone number, not a
webmail address such as
personal home telephone
Yahoo, Hotmail or
number.
Googlemail.

Signature Date

Official stamp
Name and address of organisation
If your organisation does not have an official stamp, please attach this
reference to a covering letter that has been issued on official letter headed
paper.