All information given will be considered as confidential

    Reference Request for:

    1. Please confirm the dates that the applicant was employed with you

    From To

    2. Last Position held?

    3. Please confirm number of sick days in the last 12 months?

    4. Is there any further details/information you would like to add YesNo

    If Yes Please Give Details

    5. In view of the possible vulnerable nature of the customers of the service, this position is excluded from the Rehabilitation of Offenders Act 1974, which means you may mention any criminal convictions you may be aware of.

    Are you aware of any criminal convictions; YesNo

    If Yes Please Give Details

    Name of Referee:


    Company Address:

    Contact Number:

    Email Address