Plan Tel:+670 331 2492

InternationalTimor- Email:Info.TimorLeste@plan-
Leste international.org
Rua Nu’u Laran 20 www.plan-international.org
Bairru dos Grilhos
PO Box 246
Dili, Timor-Leste

Reference Request Form

Dear      

Confidential - Request for Reference

Name of Candidate:      

National Insurance Number (Social Security):      

The above individual has been offered employment as       with Plan International
Timor-Leste and has indicated that you would be willing to provide a reference. I would
be grateful if you could complete the information below.

Please note that Plan International Timor-Leste participates in the Inter-Agency

Misconduct Disclosure Scheme (“the Scheme”). This reference request contains a
Statement of Conduct pursuant to the Scheme. By completing the Statement of
Conduct you are helping Plan International Timor-Leste reduce the risk that the
individuals we hire pose a safeguarding risk to our beneficiaries, staff, associates and
charitable assets.

All information provided to Plan International Timor-Leste will be held in strict

confidence and be used for our internal recruitment process only.

May I take this opportunity of thanking you in advance for your assistance; your prompt
reply would be much appreciated.
Should you have any queries, please dial +670 331 2492 and ask to speak to the HR
team.

Yours sincerely,

National Organisations Australia Belgium Canada Colombia Denmark Finland France Germany Hong Kong India Ireland Japan Korea Netherlands Norway Spain Sweden Switzerland
United Kingdom United States Programme Countries Bangladesh Benin Bolivia Brazil Burkina Faso Cambodia Cameroon China Colombia Dominican Republic Ecuador Egypt El Salvador
Ethiopia Ghana Guatemala Guinea Guinea-Bissau Haiti Honduras India Indonesia Kenya Laos Liberia Malawi Mali Mozambique Myanmar Nepal Nicaragua Niger Nigeria Pakistan
Paraguay Peru Philippines Rwanda Senegal Sierra Leone Sri Lanka South Sudan Sudan Tanzania Thailand Timor-Leste Togo Uganda Vietnam Zambia Zimbabwe
Plan Limited, registered in England no.3001663. Registered address as above.
 Plan Tel:+670 3312492
InternationalTimor- Email:Info.TimorLeste@plan-
Leste international.org
Rua Nu’u Laran 20 www.plan-international.org
Bairru dos Grilhos
PO Box 246
Dili, Timor-Leste

Candidate Name:      

Current or Previous Job Title:      

Current or Previous Job Geographical Location:      

Organisation Name:      

Capacity in which the candidate is known to you (e.g. Line Manager or HR):
     

Dates of employment:      

Reason for leaving:      

What were the applicant’s main duties / responsibilities? (Attach a job

description if you have one):

Contribution in role: [HR to draft questions we’d want employers to answer when
providing a reference for a prospective employee. Such questions might include:
What is your assessment of the following in relation to the applicant:
 Relationship with colleagues / external stakeholders / management
 Communication skills
 Ability to develop and motivate his/her staff, peers, and colleagues?
 Reliability, honesty and integrity
 Working with vulnerable populations
 Willingness to accept responsibility
 Respect for a diverse working environment
 Ability to deliver / meet deadlines
 Attention to detail
 Teamwork
 Ability to work without supervision
 Sharing knowledge and learning
How was the candidate’s overall contribution?

Statement of Conduct:
Was the Candidate found1 to have committed Workplace Misconduct2 during

1
“Found” for these purposes shall mean that, in accordance with your organisation’s own relevant internal
processes and standards, Misconduct has been determined to have occurred.
2
Workplace Misconduct refers to:
(a) Actions, whether physical, sexual or verbal, which pursuant to relevant legislation or your
organisation’s internal policies, amount to abuse, exploitation or intimidation of a child, young
person, vulnerable adult or other individual.
(b) Sexual exploitation, sexual abuse or sexual harassment, according to the UN Definitions of these
terms: Sexual harassment is defined in the UNSG's bulletin ST/SGB/2008/5. Sexual exploitation
and abuse is defined in the 5 Oct 2016 UN Glossary on Sexual Exploitation and Abuse.
(c) Actions amounting to theft, fraud, bribery or corruption according to relevant legislation or your
organisation’s internal policies.
 Plan Tel:+670 3312492
InternationalTimor- Email:Info.TimorLeste@plan-
Leste international.org
Rua Nu’u Laran 20 www.plan-international.org
Bairru dos Grilhos
PO Box 246
Dili, Timor-Leste

the period of employment defined above? (please tick as appropriate)

Yes
No

If Yes, please provide further details:

The nature of the Misconduct is      

I am unable to specify the nature of the Misconduct
because of the following legal / regulatory requirements:      

If the answer is yes, was a Disciplinary Measure3 imposed upon the Candidate?
No, for the following reasons:      

Yes, the Disciplinary Measure was      

Date of Disciplinary Measure:      

I cannot provide an answer

to this question for the following reason(s):      
To your knowledge, are there any concerns in relation to the suitability of this
candidate working in an environment where the protection and safeguarding of
children is an important aspect of Plan’s work?
Yes
No
If Yes, please provide further details:      

Has the candidate been subject to disciplinary action during the last 12
months?
Yes
No

(d) Actions related to harassment, bullying or discrimination according to relevant legislation or your
organisation’s internal policies.
(e) Any other form of gross misconduct, which for the purposes of this references refers to an act so
serious that it justifies dismissal without notice, for a first offence.
3
Disciplinary Measure means the sanction applied by your organisation to the candidate if they have been
found to have committed Workplace Misconduct following your organisation’s investigation and disciplinary
process.
 Plan Tel:+670 3312492
InternationalTimor- Email:Info.TimorLeste@plan-
Leste international.org
Rua Nu’u Laran 20 www.plan-international.org
Bairru dos Grilhos
PO Box 246
Dili, Timor-Leste

If Yes, please provide further details:      

Name and Title:      

Organisation:      

Date:      

Signature: