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REFERENCE REQUEST – Verbal/Written

Name of Applicant
Last Position held
Length of service claimed by applicant

Reason for Leaving

Your name & job title

Your work relationship with the applicant

Your company address

PLEASE COMMENT ON THE FOLLOWING (tick boxes)


Poor Fair Good Excellent
General Performance ~
Capacity for Work ~
Customer Service ~
Problem Solving ~
Attention to Detail ~
Team Work ~
Attitude Towards Job ~
Communication Skills ~

Honesty YES NO

How many days has the applicant been sick/absent during the past 12 months?

During the past 12 months, have there been occasions when it has been necessary to council the applicant under
your disciplinary/performance procedures? (If yes please give details)

Would you re-employ this person, if not, why not? As per company policy

Is there any further information you feel we should be aware of?

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I confirm that I am authorised to give this information

Signed: …………………………… Name: ………………………….. Date:……………………


Please validate with Company stamp

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