Name of Applicant: *

First

Last

Email *

Tel No:

How do you know the applicant? *

If employer, please confirm dates of employment:

How long have you known the applicant?

Why did the applicant leave your employment?

Are you aware of any reason why the applicant should not be involved in the care of vulnerable adults and/or children, such as a current drug addiction, poor interpersonal skills, criminal activity or personal circumstances?

Subject to a suitable vacancy and policy permitting would you re-employ the applicant?

Has the applicant ever been responsible for finances and/or handling cash?

GENERAL STATEMENT Please comment on your previous contact with the applicant and any other comments on their suitability for this post

Referees Name:

Job Title: (if known through a professional capacity)

Organisation (if known through a professional capacity) - If necessary may we telephone you to discuss any of the information contained in this form?

Telephone No:

Date:

Name & Signature:

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