Employee Reference Request
Only complete Name and Signature
Reference Request For
*
First Name
Last Name
Signature
*
Send Form
Send Form
Your Name
First Name
Last Name
Your Position
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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
Has the candidates honesty and integrity ever been brought into question that you are aware of? (Please comment)
Level of performance
Excellent
Good
Satisfactory
Poor
Would you consider candidate to be a rehire?
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
Format: (000) 000-0000.
Should be Empty: