ࡱ> ^`]#` Xbjbjmm @\o ''''''''$w(h*B'9B'{' ''!" 0LF(t"#'0'"c+(c+4"c+"B'B'(' REFERENCE REQUEST FORM The person named below has applied for the stated post within our organisation and has given your name as a referee. Please answer all relevant questions, sign and date the form, and return it to us in the envelope provided marked Private and Confidential, by [Insert deadline date]. Name of ApplicantPost Applied forOrganisation General InformationReferees name Position Address Telephone No. In what capacity do you know the applicant?How long have you known the applicant? Employment InformationDates of employment Capacity in which employedMain dutiesSalaryReason for leavingNumber of days absent through sickness/injury in the last year Assessment of Performance Please rate the person on the followingPoorAverageGoodExcellentTeamworkHonestyPunctualityReliabilityAttitude Child ProtectionThis post involves substantial access to children/vulnerable adults. Is there any reason at all to be concerned about this applicant being in contact with children/vulnerable adults? Yes % No % If  Yes , we may contact you in confidence. Other InformationPlease comment on the ability of the applicant to carry out the duties of this post, with reference to the enclosed Job Description and Person Specification In your opinion is the any reason why the applicant should not be appointed to this post? Do you have any further information or comments which you would wish to offer about the applicant, bearing in mind the post for which they have applied?  Data ProtectionThis information is being collected by [INSERT NAME OF ORGANISATION] for the purpose of recruitment and selection. If you are giving a reference on behalf of a present or previous employer, the subject will be entitled to see it. If the applicant is successful the information will be held on file for the duration of their employment. If the applicant is unsuccessful the information will be held on file for a maximum of twelve months and then destroyed. Signed: ... Date: .. 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