J & M Employee Reference Request Form

J & M Reference Form
You can give a reference here utilising our online referencing system. Please check the information supplied below. This role is working with vulnerable Adults and Children and as such we would really appreciate you taking the time to complete this reference to the best of your knowledge.
Name *

First Name Last Name
Your Name & Position *
Company Name & Address where worked with candidate *
Relationship with candidate *
1. Employment Details
Date Employed From *

Day Month Year
Date
Date Employed To *

Day Month Year
Date
Candidates Job Title *
Reason For Leaving *
Re-employ? *

Yes No
Comments/further information
2. Please Comment On The Following
General Conduct *

Excellent Good Satisfactory Poor
Timekeeping *

Excellent Good Satisfactory Poor
Communication Skills *

Excellent Good Satisfactory Poor
Relationship with colleagues/nursing staff *

Excellent Good Satisfactory Poor
Relationship with patients/service users *

Excellent Good Satisfactory Poor
Level of performance *

Excellent Good Satisfactory Poor
Are you aware of any suspicious proceedings, Policy investigations or disciplinary action? *
Additional comments. If you have ticked satisfactory or poor for any of the above please provide us with further explanatory information
I declare that to the best of my knowledge the information I have given in this reference is correct and complete *

I Agree
E-mail
example@example.com
Phone Number

Area Code Phone Number
Signature

Clear
Should be Empty:

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J & M Reference Form