Request for Referees & Consent

All offers of employment by Excellerent Technology Solutions are subject to satisfactory fulfilment of
employment reference checks. Please use this form to provide us with the details of three most recent
employers who can be contacted to gain an employment reference on you (three distinct
organisations - line manager or HR details only). One of these referees should be the current or most
recent employment - we will select two of the three references to contact.

By providing this information, you are agreeing that once you have accepted your offer of employment
we may commence and complete the reference process.

Reference #one (this should be your current or most recent employer)

Full name
Organisation & Job title
Address
Work email address
Contact telephone number
Relationship to referee
Period of employment

Reference #two
Full name
Organisation & Job title
Address
Work email address
Contact telephone number
Relationship to referee
Period of employment
Reference # three

Full name
Organisation & Job title
Address
Work email address

Contact telephone number

Relationship to referee
Period of employment

I authorise Excellerent Technology Solutions to take steps to confirm and verify my employment, my
education, and other stated activities. I also consent and authorise my professional references, including
my current and former employers to provide any and all relevant information concerning my
employment record.

Full name

Signature
Date