Employer’s reference – Page 1 of 2

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

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

Was the applicant working in a medical capacity? (Please tick)

Please note that clinical attachments and observer posts are not defined as medical practise
YES □ NO□
Was the applicant required to hold registration or a licence with a medical regulator? (Please tick)
YES □ NO □
If “yes,” please give the name of the
relevant medical regulator

Please provide the name of the authority that

regulates doctors in your country, for example
the General Medical Council, UK, not the
name of an individual person.

If “no,” please explain

Why was the applicant allowed to work in a

medical capacity without holding registration
or a licence with a medical regulator?

Are you aware of any issues that call into question this doctor’s character, conduct or fitness to
practise? (For example have they been subject to any disciplinary proceedings whilst employed by
you) YES □ NO □
If “yes,” please provide details
Employer’s reference – Page 2 of 2

I confirm that the information I have given is true and accurate to the best of my knowledge
THIS FORM MUST NOT BE COMPLETED BY THE APPLICANT.

Full name Position

Telephone number Email

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