Reference Request - Clover Healthcare Group

Reference Request Form

Thank you for taking your time to fill in this form!

Applicant Name

First

Last

Date of birth

Job title

Start date

Leaving date

In what capacity do you know the applicant?

Referring to the job description, please describe the applicant’s ability to undertake their role

Please inform us of any disciplinary actions that might have been taken against the applicant:

Would you re-employ the applicant?

To your knowledge, has the applicant ever been convicted of a criminal offence (subject to Rehabilitation of Offenders Act 1974 Provisions)?

Please rate the applicant on the following characteristics.

	Excellent	Good	Average	Poor
Communication	ExcellentCommunication Excellent	GoodCommunication Good	AverageCommunication Average	PoorCommunication Poor
Ability	ExcellentAbility Excellent	GoodAbility Good	AverageAbility Average	PoorAbility Poor
Character	ExcellentCharacter Excellent	GoodCharacter Good	AverageCharacter Average	PoorCharacter Poor
Conduct	ExcellentConduct Excellent	GoodConduct Good	AverageConduct Average	PoorConduct Poor
Attitude	ExcellentAttitude Excellent	GoodAttitude Good	AverageAttitude Average	PoorAttitude Poor
Loyalty	ExcellentLoyalty Excellent	GoodLoyalty Good	AverageLoyalty Average	PoorLoyalty Poor
Co-operation	ExcellentCo-operation Excellent	GoodCo-operation Good	AverageCo-operation Average	PoorCo-operation Poor
Ability to work with others	ExcellentAbility to work with others Excellent	GoodAbility to work with others Good	AverageAbility to work with others Average	PoorAbility to work with others Poor
Trustworthy	ExcellentTrustworthy Excellent	GoodTrustworthy Good	AverageTrustworthy Average	PoorTrustworthy Poor
Hardworking	ExcellentHardworking Excellent	GoodHardworking Good	AverageHardworking Average	PoorHardworking Poor
Punctual	ExcellentPunctual Excellent	GoodPunctual Good	AveragePunctual Average	PoorPunctual Poor

Do you have any other information regarding this application, which you believe, should be known to us as prospective employers?

Reference Name

First

Last

Reference Email

Position

Date

Signature

Clear Signature

Reference Phone

Company Name

Company Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Are you happy for us to contact you about the information you have provided?

Are you human?