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REFERENCE REGARDING (name of applicant)
Period of work:
From: MM / DD / YYYY
To: MM / DD / YYYY
Capacity in which employed:-
Reason for leaving:-
Please indicate your opinion of the above named by marking the appropriate section below:-

General Conduct
Excellent Good Average Poor
Attitude & co-operation
Excellent Good Average Poor
Honesty
Excellent Good Average Poor
Initiative
Excellent Good Average Poor
Timekeeping
Excellent Good Average Poor
Number of days absent in last 12 months:-
Please confirm the number of occasions this relates to:-
Number of days taken for parental leave:-
Are you aware of any medical condition that may affect work performance?
Yes No
Please provide details of salary before the applicant left:
Would you remploy?
Yes No
If no, please state reason
Name:
Positon:
Date:
Email:
Telephone Number:
Do Not Fill This Out

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